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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> rFOFOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> A Telephone: (209) 466--6781 <br /> APPLICATION 'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4d <br /> THIS PERMIT EXPIRES I 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 a.Ad the Rules and Regulations of 'the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name 4 � � License foo .Phone y4t, _p 6 <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN /-7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> f Other / J <br /> DISTANCE 'TO NEAREST: SEPTIC TANK SEWER LINES - PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD ' CES-SPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation . /a� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> [ Irrigation Gravel Pack Depth of Grout Se <br /> Cathodic Protection i= Rotary Type of GroutZf <br /> , " <br /> Disposal t OtherOther Information . . * <br /> { Geophysical - i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump v' - A.P. <br /> PUMP REPLACEMENT: %/'' State Work Done <br /> PUMM !REPAIR: /? State Work Done <br /> ES,T RUCTION OF WELL: Well Diameter << r Appro mate Depth cSi�) <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 regul-ring-6-11 '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 puttingthewell in use.. The above <br /> information ie true to the•best of my knowledge and belief.' I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND MINAL INSPE CION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' 1 FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY I DATE I-S-2Sr <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION _ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t iE H 1426 Rev. 1-74 1-74 2M <br />