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SAN JOAQUIN LOCAL HEALTH DISTRICT �r <br /> FOR OFFICE USE: 1601 E. ,Razelton 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. 1QQ862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ), € CENSUS TRACT <br /> Owner's Name Phone �- <br /> Address D 3.-- City <br /> Contractor's Name License #42� Phone]Qt--� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION j / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ /j PUMP REPAIR / / PUMP REPLACEMENT f� <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 v <br /> Domestic/public Driven Gauge of Casing . Q <br /> Irrigation Gravel Pack Depth of Grout Seal N <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: — l� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. __2 J <br /> PUMP REPLACEMENT: <br /> 5tate Work <br /> Don� �CX Z ( <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 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is t e to the best of m knowledge and belief. I WILL CALL FOR A GROUT INSPEGTIOIV <br /> PRIOR TO GROUTI D A F INSPE ION. <br /> SIGNED TITLE <br /> W, PL T PLAN 'ON RE FRSE SIDE) 77 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f _1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4.� DATE / ,2- - -71 <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />