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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW,' FF10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a dl-M— � <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,� CENSUS TRACT <br /> Owner's Name '� � i�-i Phone ` / <br /> Address X City <br /> Contractorts Name I 4 License 4. 11 Phone 7 / <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN '/? RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION E/ PUMP REPAIR / 7 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 SPECIFICATIONS '40 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> k ' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing I <br /> Zs <br /> k ;Irrigation avel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> t Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 6( CIV <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ,SES TRUCTION 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 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. my.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROJITING AND A ZINAL X4SPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� DATE /,1- 5� <br /> ADDITIONAL COMMENTS: \ <br /> PHASE I , GROUT, INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BYDATE 't-L -7S INSPECTION BY ATE7-/��, <br /> � ,kE H1426 <br /> Rev. 1-7 1-74 2M <br />