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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —FO E.OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. jl7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete In Triplicate) <br /> Application is tereby 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 Jpaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION + <br /> 422,226,6 CENSUS TRACT <br /> Owner's NameC <br /> Phone <br /> Address c � <br /> pity <br /> Contractor's Name License # �j€�Phone <br /> - 2- � �7i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN%/ RECONDITION /-7 DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMEN—TgF <br /> Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ..-�- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 45- <br /> PROPERTY <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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br />'I hereby agree to comply with all laws and regulations of the San Joaquin Local Health bistrict <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 b est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> FRIOR TO GR <br /> MTING AND A FIRAL INSJPECTION. <br /> SIGNED _ TITLE � �i. <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASEAIIIJTINAL INSPECTI91N <br /> INSPECTION BY . ' DATE INSPECTION BY DATE , <br /> { <br /> E H 1426 Rev. 1-74 , 1/77 ' 2M � <br />