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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: &/,d 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR "•WETI CONSTRUCTION OR PUMP PERMIT Permit No. (,�J ; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 7 <br /> (Complete In Triplicate) <br /> Application i <br /> p ) <br /> Ap <br /> P s 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 CENSUS TRACT <br /> Owner's Name Q�e A it Phone 3 -- <br /> Address <br /> City gZ4 <br /> c - <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL "/�*/' DEEPEN/_/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION /`/ FUMP REPAIR PUMP REPLACEMENT /? <br /> Other <br /> f" .+ s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6'L7 ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER L� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS t <br /> Industrial tt.� Cable Tool Dia. of Well Excavation11 <br /> Domestic/private. 22 <br /> Drilled Dia. of Well Casing .l <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 B <br /> PUMP INSTALLATION: Contractor <br /> Type lo£.."'Pump rt <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work--Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> e - 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 />?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITL , <br /> (DRAW PLOT:PLAN ON ,REVERSE SIDE) j <br /> PHASE I <br /> FOR DEPARTMENT-USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION PHASE IiI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY l DATE <br /> E H 1426 Rev. 1-74 1/77 2M /'� <br />