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^ ell <br /> . SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> FOB;OFFICE USE. 1601 E. Hazelton Ave. ; Stockton, Calif. Y <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 70 r <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,..., Date Issued X76 <br /> (Complete In Triplicate) <br /> Application is hereby'made to the San Joaquin Local Health Diatrict,"for a permit" to ,construct <br /> and/or install:the work herein described. This application is made -in -compliance with San,Joaquin <br /> f County Ordinance No. 1862 and the Rules "and Regulations of the San -Joaquin:,Local Health District.: <br /> JOB ADDRESSILOCATION w , <br /> ju CENSUS TRACT <br /> ,., <br /> . Owner's Name � � •Phone . <br /> Address ..#. _ ... '— <br /> Contractor's Name <br /> d : License <br /> ' - .ex .Phone <br /> TYPE OF WORK (Check): NEW WELL "/ DEEPEN '/_7 RECONDITION /_7DESTRUCTION /7 . <br /> PUMP INST/ALLATION /� PUMP REPAIR PUMP REPLACEMENT /f <br /> Other-1/ s. . Vi . <br /> DISTANCE TO NEAREST: SEPTIC ;TANK SEWER LINES t PIT PRIVY R <br /> SEWAGE �DISPOSAL D FIELCESSPOOL/SEEPAGE PIT OT-HER"/ <br /> f <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC' DOMESTIC WELL y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIPICATIONS <br /> Industrial ^ Cable Tool Dia.,'of Well Excavation i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public �� Driven Gauge of Casiag - v <br /> Irrigation r Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Typelof Grout s <br /> Disposal Other Other Information <br /> on ^ <br /> Surface Seal Installed ;By <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of,PUMP t H.P. "_ { <br /> PUMP REPLACEMENT: . / / State Work Done <br /> � _ .�: _ -- •�._ _ _ - _ <br /> State Wo-rk Done - <br /> DESMUCTION "OF WELL: Well Diameter <br /> 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"construttion. .�Within FIFTEEN DAYS <br /> %after completion of my-work on anew well,NI will furnish .the•,San Joaquin-:,Local Health District a <br /> WELL DRILLERS REPORT of the well�and notify,-them before ;purring.-jthe..well. in'use... The above <br /> information is true to the-best .of'`my...knowledge acid belief. �.;.I WILLS CALL FO A " INSPECTIU <br /> 'GROUT <br /> PRIOR TO GROUTING AND F1 INSPECTION. _ <br /> SIGNED TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDE <br /> _._ . -_ FOR DEPARTMENT USE ONLY <br /> PHASE_ I . _..���.;.::--- M <br /> PPLICATION ACCEPTED -BY �. .'_ r <br /> A <br /> DATE <br /> ADDITIONAL COMMENTS:'i <br /> PHASE II GROUT INS CTION PHAS II INSP$CTIO <br /> INSPECTION BY t DATE •INSPECTION .BY . DATE "• ] <br /> .EH 1426 Rev._.l-74 <br /> r . ...� <br />