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JbAQUTN LOCAL HEALTH DISTRICT COPY <br /> FGA OFFICE USE: 1601 E. Hazelton 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 -3 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a peftit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin. <br /> Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joa q <br /> JOB ADDRESS/LOCATION �` .I I t�/LCENSUS TRACT ' <br /> Owner's Name Phone eS� <br /> Address ' C t:(J City <br /> i <br /> Contractor's Name d License # 3�/6?S Phone '�5:2- <br /> i <br /> TYPE OF WORK (Check): NEW WELL/?' DEEPEN — RECONDITION 17 DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /� CIO <br /> Other / O <br /> / <br /> DISTANCE TO NEAREST: SEPTIC TANK %4' SEWER LINES Se 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 /> L---Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of CasingC. <br /> Irrigation Gravel Pack Depth of Grout Seal u�a <br /> Cathodic Protection --Rotary Type of Grout <br /> Disposal Other Other Information ~� <br /> Geophysical Surface Seal Installed By: <br /> F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> . DESTRUCTION OF WELL: Well Diameter ��{ Approximate Depth d _ <br /> Describe Material and Procedure �R <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 G . TING AND A FI INSPECTION. <br /> SIGNED TITLE <br /> (DRAW.- PLAN ON RE -RSE SIDE <br /> FOR DEPARTMENT USE ONLY -g-2� <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: 19 <br /> PHASE 11::G2ff INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE _ ) -?-y 7Y INSPECTION BY DATE 7-751- <br /> 3/76 <br /> 7 <br /> E H 1426 Rev. 1-74 <br />