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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE. OFFICE USE: ad 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby madelto the San Joaquin Local Health District for a permit to construct <br /> and/or install the work heielin described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sail Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> C <br /> I Owner's Name � (� ��' Phone <br /> Address Cit, <br /> E Contractor's Name, el _ <br /> License &KPhone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /— . <br /> PUMP INSTALLATION / I PUMP REPAIR I / PUMP REPLACEMENT <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i <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 U <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. df Well Casing <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack` Depth of 'Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical- ..,_ _ _ _ _ . , _Surf Installed B <br /> __PUMP INSTALLATION: -' Cont'ractor <br /> Typeof Pump H.P. <br /> 1 PUMP REPLACEMENT: State .Work Done �, <br /> IY <br /> PUMP .REPAIR: /_7 Sta-teWork 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 a new well, I will furnish the San Joaquin Local Health District 8 <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 CAI,%i FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AN A IN INSPECT—ION. <br /> {! SIGNED / TITLE/ - <br /> : <br /> DRAW PI: T PLAN ON REVERSE SIDE) J: :: <br /> t FOR DEPARTMENT USE ONLY <br /> r <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE Ii ROUT INSPECTION PHASV"/FINAVINSPECTION <br /> 4 INSPECTIOR BY DATE INSPECTION BY ATE�;7_- <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />