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k <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Y Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� j <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 and Regulatio s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Nance Phone <br /> Address �+ City <br /> Contractor's Name xf: License 4,21 PhoneF <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN-/_/ RECONDITION /_� DESTRUCTION <br /> PUMP 11 LATION 2KI PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -55 2 7 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 Xf ' <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: <br /> i <br /> PUMP INSTALLATION: Contractor [: <br /> Type .of PuTV H.P. <br /> PUMP REPLACEMENT:'_. / / State Work^Done - <br /> PUMP,.;REPAIR: /. / State Work-Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe 'Material and Procedure <br /> • F <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 myknowled and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A Fly)04ASPECTION. <br /> SIGNED TITLE TI iii <br /> DRAW-PLOT' PLAN ON REVERSE SIDE)~' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY + � J W DATE 7 " -7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4: DATE <br /> I?W <br /> 3/76 2?`f <br /> E H 1426 Rev. 1-74 <br />