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5F SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL 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 Z-7G <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 Joaquin <br /> County Ordinance No. 1862 and t Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Dp' �, G. � CENSUS TRACT <br /> Owner's Name Phone <br /> Address . CityaSki <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INST TION / PUMP REPAIR/—/ -PUMP REPLACEMENTI-7 <br /> Other / / __ � 4� . , c.�=, _,.w„ -- <br /> r <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 a -, <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 /> qP&A" <br /> t PUMP INSTALLATION: Contractor <br /> F <br /> Type of Pump .P. WAVY <br /> PUMP REPLACEMENT: / / S e Work Done <br /> PUMP .REPAIR: / State Work Dane r. - <br /> _.._ <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 /> t 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 INSPECTIp'N <br /> PRIOR TO:'GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE 22 <br /> iJ57TPLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> rr <br /> APPLICATION ACCEPTED: BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY V DATE, f <br /> �� <br /> E H 1426 Bev. -1-74 u <br />