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i� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORe'OFF,ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 . Telephone: (209) 465 .6181 <br /> iMl APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /4 <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 i6stall, the.work herein described.. This application- is rude in compliance with San Joaquii <br /> County O�hdinance No. 1862 and the Rules nd. Regulations of- the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner`s' Name .J�� Phone C,73/ <br /> Address C� i 1�.® �7 }� �/V city , <br /> Contractor s Nameg) .� License #'&�zj-hone`/ 8 <br /> TYPE OF WORK (Check): NEW WELL /!SF DEEPEN4 /- RECONDITION /_7 DESTRUCTION _� <br /> PUMP INSTALLATION / / PUMP REPAIR /—/—PUMP REPLACEMENT <br /> Other / / <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 SPECIFI 0 S <br /> industrial ' Cable Tool Dia, of Well Excavation <br /> ;Dtilt <br /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge,of Casing 70 <br /> '. Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection r Rotary Type of Grout' C,jn^/ <br /> Disposal M Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ,i Type" of Pump H.P. <br /> PUMP REPLACEMENT: j // IState Work Done <br /> PUMP ..REPAIR: - -/-7 -1-State Work Done <br /> ESIRUCTION OF WELL: Well Diameter <br /> _ Approximate D h <br /> Describe Material and Procedure Ve� <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and thei�atate 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 /> informal on is true to the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO.�JGROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> .0i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE II <br /> APPLICATION ACCEPTED Y DATE <br /> ADDITIONAL COMMENTS: <br /> I OUT INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION TE INSPECTION- BY DATE <br /> 1 <br /> E H 2b Rev174 1-74 2M <br />