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�! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,74!-s41c!2 <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedA/ <br /> Application <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 Phone - T _ <br /> Address 473 City <br /> Contractor's Name hop <br /> .c�.� License k ,j <br /> / Phare <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN`/_7- RECONDITION -/_7 DESTRUCTION <br /> PUMP INSTALLATION j_/ 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-UNE ---PRIVATE-DOMESTIC WELL' o PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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 /> DisposalOther ! �w Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , -- �c <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done t <br /> PUMP REPAIR; ` State Work Done - <br /> ES•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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIJQ Mk A F NSPECTION. <br /> SIGNED TITLE � <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 17 <br /> APPLICATION ACCEPTED BY zaDATE �"� `` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �- - <br /> E H 1426 Rev. 1-74 1-74 2M <br />