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OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 16 <br /> FF TOR 01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 724,2/6' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) lw" <br /> Application is hereby made to the San Joaquin Local Health District for a perml to onsC uet Z <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 �j q CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> r Contractor's Name [� ,� License '17fp 'Phone �� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 /> ��Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal /Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor PA/YL,fi7 <br /> Type of Pump H,P` <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 I 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. A <br /> SIGNED 17 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ` <br /> FOR DEPARTMENT USE .ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED4 BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHAS GRO 4�T <br /> ECTION PHAS , III/F NAL INSPECTION <br /> INSPECTION BY E �p� INSPECTION BY DATE 7 <br /> 4s� ' .� ` <br /> E H 1426 Rev. . 1-74 0, 77 /qm -.c <br />