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a r <br /> 3 <br /> r <br /> SAW JOAQUIN LOCAL HEALTH DISTRICT + <br /> FOR ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit TIo. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> k 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 Re ulationa of the San Joaquin Local Health District. : <br /> JOB ADDRESS/LOCATION /+�?p •:3 �J• CENSUS TRACT j <br /> Ownera NaPhoneme c <br /> Address 4, City _`. <br /> R Contractor's Name ' fC License 0 Phone <br /> TYPE AF WaRK. (Check): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> . _ <br /> E PUMP INSTALLATION I I PUMP REPAIR I_7 Purim REPLACEMENT <br /> .y Other L/ .. <br /> r' <br /> DISTAyCB^TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTSBR <br /> ' PROPERTY LINE PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> .-NTENDED USE TYPE OF L CONSTRUCTION SPECIE TIONS ' <br /> I ustrial able Tool Dia. of Well Excavation <br /> estic/private Drilled Dia. of Well Casing <br /> Domestic/public DrivenGauge of Casing JA <br /> s rigation 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 /> ptit3P'-INSTALLATION: Contractor �(,� sc <br /> �° ' <br /> Type �of Pu .P. <br /> h <br /> PUMP REPLACEMENT: Ll State Work Done <br /> 41 <br /> PUMP REPAIR: L7 State Work Done . <br /> r <br /> DESTRUCTION OF -WELL: Well Diameter Approximate Dept <br /> Describe Material and Procedure <br /> I'heieby,agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> V 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 furni3h the San Joaquin Local Health District a <br /> WFI.L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the t of my knowledge and belief. I WILL LL FOR A GROUT INSPECTION <br /> PRIOR TGG I G AN A F I IPEdfION. <br /> SIGNED TITLE <br /> DRAW P FLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I I <br /> DATE 2-r � 7 6 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COK4MTS: <br /> PHASE It GROUT INSPECTION ri PHASE III FINAL INSPECT ON/ <br /> INS-,EM 'V BY S,• _ DATE pli.iSFECTION BX e"s. DATE <br /> E H 1426 Rev. 1-74 3/76 7M{ <br />