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SAN JOA(jUIN' LOCAL HEALTH DISTRICT <br /> F0 �3FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,? <br /> THIS TERMIT 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 withySan"Joaquin <br /> County Ordinance 'No. 1862 and the Rules and Regulations of the San,'J_opaquin Local Health District:^ <br /> ,JOB ADDRESS/LOCATION 'S ICENSUS TRACT <br /> Sf lam/ �1.5(l/ Y/CfiW1--5 <br /> p G <br /> Owner's Name Phone o p�'��o �6 <br /> Address Z <br /> 3-5-- L� fig- c9',5`3 74 City <br /> C�fl a <br /> Contractor's Name ���� /:?/)L�ps License #f� aone444% <br /> - 1 <br />. TYPE OF WORK (Check)a NEW WELL / DEEPEN '/� PRECONDITION � DESTRUCTIONf j- <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 SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation � <br /> Domestic/private Drilled Dia. of Well Casing Iv <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 /> PUMP INSTALLATION: . Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , State Work Don <br /> PUMP ,IEPAIR: / / State Work Done <br /> DESTRUCTION 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 anew 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED /dva. mow- - _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEIII AL INSPECTION <br /> GPM <br /> INSPECTION BY DATE INSPECTION BY DATE �. <br /> f <br />�. E H 1426 Rev.. 1-74 -- <br />