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SAN JOAQLTIN LOCAL HEALTH. DISTRICT <br /> FOR 0 ICE 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 , / -7� <br /> 1 (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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> s <br /> Owner's Name rjCp m0 Phone <br /> Address o� _ GI City � '`'°��: _ <br /> Contractor's Name .,. License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECDNDITION / / DESTRUCTION /� h-'• <br /> PUMP INSTALLATION/X/ PUMP REPAIR / / PUMP REPLACEMENT <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 /> Domestic/public Driven Gauge of Casing <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 /> PUMP INSTALLATION: Contractor - +� H.P. <br /> Type .of Pump - l <br /> PUMP ;Iva i <br /> State Work Done <br /> r PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> Desciibe 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-be'st of my k e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND A FIN INS N. ITLE <br /> k SIGNED <br /> Y3i�'T PLAN ON FRSE SIDE)- <br /> ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE / ' �• "T�r <br /> ADDITIONAL COMMENTS: --7- L <br /> PHASE II GROUT: INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4 � DATE 1,2 -40'1'b" <br /> 41 <br /> E H 1426 Rev. 1-74 3/76 2m - - <br />