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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 /� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.; _tf <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L��_ _ <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 14t 24 8 ALLoA, 62,zas-rPhone <br /> Address S A P., City A R k23 dAR v� <br /> f <br /> Contractor's Name ( , rte p� :�✓ License # Phone a a g <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /? <br /> Other /_7 <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: 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: " State Work Done t <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'con'struction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the'' Sari•,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,4& GROUT INSPECTION <br /> PRIOR TO GROUTING AND FTN INSPECTION. 10 <br /> SIGNED TITLE, <br /> (DRAW- PLOT PLAN 'ON REVERSE SIDE) <br /> F - ,,REPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTY SDATE ^ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1»74 <br /> 3/76 2M <br />