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SAN JOAQUIN LOCAL HEALTH DISTRICT _--- <br /> M FIOF CE USE: 1601 E. Hazelton Ave..-, Stockton, Calif. <br /> Telephone; .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Q�(Complete In 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS,/LOCATION L ry CENSUS TRACT <br /> Owner's Name Phone IR X ~ 7 a <br /> Address ;. <br /> City _ Ae&C /4/010 <br /> Contractor's Name _ U _._,.._ - License 460 Phone <br /> TYPE OF WORK. (Check): NEW-WELL '/-f DEEPEN -/7 RECONDITION /_' DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR 1-7 PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I <br /> f 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 N <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ; <br /> Geophysical <br /> _ Surface Seal Installed By_: <br /> PUMP INSTALLATION: <br /> Contractor -- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done s <br /> PUMP .REPAIR: /7 State Work Done _ <br /> E&TRUCTION 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 1 <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 GROUTIN, D A FIN IN ECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> - -.FOR DEPARTMENT USE ONLY•.- .- <br /> PHASE I ` �y <br /> APPLICATION ACCEPTEb BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHA S FINAL INSPECTION E <br /> INSPECTION BY DATE INSPECTION BY 4Lkz2&= DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />