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/ cam, 60 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB;OPFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> 4u <br /> JOB ADDRESS/LOCATION ` { r .. ,� 7`' - s * CENSUS TRACT `Zf- 1 o -3Z; <br /> Owner's Name 1 jr t i <br /> .� Phone <br /> O <br /> Address el "�� -_� <br /> City le <br /> Contractor's Name •- <br /> License # 31 Phone 7. 7V?( <br /> TYPE OF WORK (Check): NEW WELL /—f DEEPEN /-7 RECONDITION /-' DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /V/ PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY vy <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \A <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL VIl <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 <br /> Type of Pump H.P. •.y +� <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP .REPAIR: L7 State Work Done _ ,, K., -�, <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 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. 1/. fi <br /> SIGNED t" _ '�� �.-i M .TITLE .•�1 <br /> (DRAW'wnOT-PLAN ON RRVERSE SIDE) 4 <br /> PHASE I ` � �/'FW DEPARTMENT USE ONLY <br /> �- <br /> APPLICATION ACCEPTED BY DATE Z �7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION IZ PHAS , I I FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2;P— <br />