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�/ SAJOAQUIN LOCAL HEALTH DISTRICT <br /> FOA40FFICE USE: 1601 N E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a- <br /> (Complete <br /> a-(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 /> Owner's Name Phone 239-2272 <br /> Address City Manteca <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL / " DEEPEN ? RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 , 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 /> _xu.x_ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge <br /> Irrigation of Casing <br /> Irri <br /> g Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other <br /> �� Other Information <br /> Geophysical Surface Seal Installed BX: W .� <br /> PUMP INSTALLATION: Contractor A S B Electric <br /> Type of Pump H.P. f <br /> PUMP REPLACEMENT: j//- State Work Done <br /> PM 'REPAIR: 1-7 State Work Done <br /> ES•TRUCTION 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 Saiz 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 CALOFOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AN FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 0-1-'�5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRMT INSPECTION PH6,Sg FINAL INSPECTION <br /> INSPECTION BY Dc,, DATE INSPECTION BY DATE - - <br /> i E H 1426 Rev. I-74 1-74 2M <br />