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SAN JOAQUIN LOCAL HEALTH DISTRICT dry r <br /> FOE, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEWAI Permit, No. <br /> � <br /> 1;� .. <br /> c THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��Ms sued <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 Re lations of the S n Joaquin Local Health District. <br /> ag1g .� <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name - � Phone <br /> Address �d d d p City <br /> Contractor's Name License # 1?/VaFhone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION / / DESTRUCTION /_7PUMP INSTAL TION/ / PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 /> y Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing l Q <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 /> PRMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> P,UMP ,REPAIR: / / State Work Done <br /> Q C D G✓ G� 7a 5.Iz_ /'R�� L A-y✓/�o nr �� w iv i <br /> DES-TRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Material and Procedure- C�A1,- sa a -/ 7- <br /> _ 3,4�C T 6 F o eJ PWR F79-Z-� //-- <br /> I <br /> /I hereby agree to comply with all laws and regulations of the San Joaquin Local Health strict <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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND A FI INSPECTION. <br /> SIGNEDTITLE <br /> !7.(DMjkTL0T PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY jJ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE T / INAL JTNSPECTION <br /> INSPECTION BY ATE - / - INSPECTION BY TE <br /> E H 1426 Rev. 1-74 �'!!{-�.. 7zw 3/76 2H <br />