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- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE US 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the` San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �, CENSUS TRACT <br /> I <br /> Owner's Nameromo� Phone'Z 9 - //9 a <br /> i <br /> Address City _ <br /> IE <br /> Contractor's Name - , License # k <br /> 1w phone r."76 f <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION / / DESTRUCTION /� I <br /> PUMP INSTALLATION / / PUMP`REPAIR / / PUMP REPLACEMENT /R7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation <br /> SC Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - Irrigation Gravel Pack Depth of Grout Seal 4 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information .i <br /> Geophysical Surface Seal Installed By: i <br />' M <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. � I <br /> y <br /> PUMP REPLACEMENT: /jC/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree .to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to. or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion' of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well- in use. The above <br /> information is true to the best of my know,60dge a belief. I WILL CALL FOR A GROUT INSPECTION <br /> TI <br /> PRIOR TO GROUTING AND A FINAL INSPE <br /> SIGNED TITLE <br /> (WW PLO-T PLAN ON iTWERSE SIDE) E <br /> Q <br /> FOR DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S FINAL NSPECTION <br /> INSPECTION BY 4,Q DATE INSPECTION BY ATE 7-6 <br /> E H 1426 RPu• 7-74 �- <br />