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�k/ ` ' JOAQUIN LOCAL HEALTH DISTRICT <br /> on Oi ICE USE: 160:rti. Hazelton Ave. , Stockton, Calke: <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S 3/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S 7S <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 Joaquic <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sanoaquin Local Health District. <br /> JOB ADDRESS/LOCAT ON `r l/�� y / CENSUS TRACT <br /> Owner's Name V�;tf ✓ �«^ Phone <br /> Address -�)izr/�e� �L t� ,�-_•t �� City <br /> Contractor's Name J t�� � License �Z373?Aone46c41'e' <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN / / RECONDITION /_7 DESTRUCTION /-J <br /> PUMP INSTALLATION / / PUMP REPAIR /0 PUMP REPLACEMENT /_7 <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 \ <br /> D6mestic/public Driven Gauge of Casing S <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 /> O <br /> N <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Dong��l - IPI/- <br /> ti,P-/a� nim <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 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. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDY DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHAS I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 -�,• �v <br />