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JOAQUIN LOCAL HEALTH DISTRIC <br /> ?Oh OFFICE USE; 160_ Hazelton Ave. , Stockton, Ca1�_.. . <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7 & <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> implication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> lid/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 /> F)B ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone • <br /> FJdress <br /> r City <br /> V <br /> ("intractor's Name ` � License -PA�khone <br /> 7—PE OF WORK (Check.) : NEW WELL /DEEPEN RECONDITION / / DESTRUCTION /_7 <br /> . PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other - <br /> r <br /> ] ,!'STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> k) SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ! INTENDED USE <br /> TYPE OF WELL <br /> 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 /> M f p/'Irri gation Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection Rotary Type of Grout <br /> r Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> i P,.1IMP INSTALLATION: 'Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> F;...MP .REPAIR: State Work Done <br /> D,-�S-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L-hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> E 'd the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> aster 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 /> il'formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 4-COR TO ROUTING D A FINAL INSPECTION. <br /> SIGNED <br /> 7TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I J, FOR DEPARTMENT USE ONLY <br /> P <br /> s'�'PLICATION ACCEPTED BY _` _< t DATE <br /> A` DITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> LUSPECTION BY DATE INSPECTION BY DATE <br /> 7-5 <br /> E H 1426 Rev. 1-74 ; 1/77 2M <br />