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SAN JQAQUIN LOCAL HEALTH DISTP,ICT <br /> FOA,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. (�[/ <br /> Telephone: (209) 466-6781 ,.�-- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z;I- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE i5SUEDDate Issued <br /> �� � <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 /> JOB ADDRESS/LOCATION Ile= 451CENSUS TRACT <br /> Owners Name <br /> " Thane <br /> Address <br /> City <br /> Contractor's Name License #f!:taphone <br /> TYPE OF WORK (Check): NEW WELL '&V DEEPEN T7 RECONDITION /7 DESTRUCTION <br /> 1-7 <br /> PUMP INSTALLATION _ PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other /% -- <br /> DISTANCE TO NEAREST: . .SEPTIC TANK _1,4�►j SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br />,a 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 <br /> Cathodic Protection Rotary Type of Grout <br /> disposal Other Other Information <br /> Geophysical 'Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: E7 State Work Done <br /> PUMP :REPAIR: State Work Don _ <br /> REST RUCTION, 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 I <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 Sart 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 />°RIOR TO GR ING AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F `DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY DATE <br /> ADDITIONAL CommENTS <br /> PHASE II GROUT INSPECTION P S I/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Q <br /> E H 1426 Rev. 1-74 �� t <br /> 1-74 2M <br />