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.. 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-67815, ._ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT - Permit No, <br /> ij <br /> THIS PERMIT EXPIRES ] YEAR FROM DATE ISSUED Date Issued _ l <br /> j (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the workj,herein described. This application is made in compliance with San Joaquin± <br /> County Ordinance No. 1862 and the Rules and Regul tions of the San Joaquin Local Health Districtri� <br /> JOB ADDRESS/LO ION -7 _O� i <br /> US TRACT <br /> Owner's Name ' Phone ! <br /> Address / 7 Ci <br /> R : <br /> Contractor's Name License -3hone'fD��� � <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN / J RECONDITION/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �E <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> TENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ndustrial it Cable Tool Dia. of Well Excavation <br /> 41 IV�: <br /> Domestic/private �� Drilled Dia. of Well Casing <br /> Domestic/public „ Driven Gauge of Casing V]w <br /> Irrigation If Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> -Disposal i�. <br /> P r� Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: ;Contractor ! <br /> TYPe of Pump H.P. - <br /> PUMP REPLACEMENT: = State Work Done / !. <br /> PUMP .REPAIR:" /I!/ State Work Done -- -- <br /> n <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby agree -to complyi,with all laws and regulations of the San Joaquin Isocal Health istt*-Ot. <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN AXS ,._- <br /> after Completion of my work on a new well, I will furnish the San Joaquin Local health Di's.trl�� a. <br /> WELL DRILLERS REPORT of the well and notifythem before � <br /> putting the-.well in use. The above <br /> information is true to tYe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDL TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY .i DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IT g . _ INVECTION PHASEAIIZ4INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H� 1426 Rev. 1-74 1/77 ` M <br />