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k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeltor�,Av -_5 Stockton, Calif. <br /> s <br /> Telephone:- (209') 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued k-6 <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name Phone <br /> Address City _A�d� <br /> t . License # a 90�, Phone <br /> Contractor s Name <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTALLATION/ / PUMP REPAIR/ I PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /1P, 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 5-l} <br /> Cathodic Protection �� Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor � /.4 ` r /i") <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-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 /> E PRIOR TO G OUTING. ANDA INAL I PELT N. <br /> SIGNED TITLE <br /> D I'Ib T' P AN 'ONREV SE SIDE <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I 1-�Z 7 4 <br /> APPLICATION ACCEPTED BY l/!/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA5 I/FIN IN <br /> INSPECTION Y ATE INSPECTION BY DATE r- r- <br /> ' 3/76 2M <br /> F N 142h RP_v_ 1-74 <br /> " U <br />