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I. SAN JOAQUIN LOCAL`HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> II <br /> t1„ „_ Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '] O <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued Jy <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. 1$62 anc�the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION H' <br /> CENSUS TRACT <br /> r <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name f p <br /> License #3� 'hone <br /> '�F a <br /> TYPE OF WORK (Check) : NEW WELL /Lf-_DEEPEN RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /J7/` PUMP REPAIR / / PtiMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK J�0 _ SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> 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 ,i <br /> /private 1i Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing f <br /> Irrigation .E Gravel Pack Depth of Grout Seal <br /> Cathodic Protection! Rotary Type of Grout <br /> Disposal Rotary <br /> Other Information <br /> Geophysical <br /> Surface Seal Installed B s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> n � <br /> PUMP REPLACEMENT: / "/ State Work Done <br /> PUMP .REPAIR: <br /> I / State Work Done . <br /> it <br />).ESTRUCTION OF WELL: Well Diameter <br /> %Y� ' <br /> Approximate Depth <br /> Describe Material and Procedure <br /> w <br /> I hereby agree to comply with al]_ 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 /> 4ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above E <br />_nformation is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT IN PECTION f <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> r <br /> (DRAW PLOT PLAN ON REVERSE SID ) I <br /> FOR DEPARTMENT USE ONLY r <br />'RASE I ! � _ <br /> APPLICATION ACCEPTED BY <br /> i1 <br /> ADDITIONAL COMMENTS: DATE <br /> P E II GROUT INSPECT O PHA II /FI AL INSPECTION <br /> NSPECTION BY &AqDATE" Q INSPECTION BY DATE S <br /> E H 1426 Rev. • 1-74 2M <br />