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l�Y SAN JOAQUIN LOCAL HEALTH DISTRICT J <br /> FOHrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. c_ 1,2- <br /> THIS <br /> ,THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 the Rules , nd Relations of the San Joaquin Local Health District. <br /> ! <br /> JOB ADDRESS/LOCATION ENSUS TRACT. <br /> a <br /> Owner's Name aw Phone <br /> E <br /> Address i. <br /> City <br /> Contractor's Name License # Phone C74 T <br /> TZ <br /> 2 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /�% PUMP REPAIR /_7—PUMP REPLACEMENT /-7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE- <br /> PIT_-PRIVY_- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ---PROPERTY-LINE..-..PRIVATE-DOMESTIC'WEI:I;"­-... ' PUBLIC�DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> t Industrial X Cable Tool Dia. of Well Excavation <br /> t Domestic <br /> /private Drilled Dia. of Well Casing f1 I , <br /> Domestic/public Driven Gauge of Casing ,or <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> i Cathodic Protection Rotary e y Type of Grout _ <br /> Disposal Other` - Other Information < � <br /> Geophysical <br /> . .,, 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: ,.R... <br /> L7i—State—Work:Done-�- - --- - -- <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desc ibe Material and Procedure . . — —; <br /> I hereby agree to comply with all laws and regulions f the San Joaquin Local Health Districts <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYSS <br /> After completion of my work on a new well, I will furnish the .San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in.use.. The above a <br /> information is true to the best.of. my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY DATER - C <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE <br /> `�c� - ,.. !" INSPECTION BY DATE 1/7 <br /> E H 1426 Rev. 1-74 <br />