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SAN JOAQUIN LOCAL HEALTH DISTRICT f�J <br /> FOR OFFICE USE: 1601 E. " Hazelton Ave. , Stockton, Calif. O` <br /> Telephone: .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued//`/�)'7 <br /> I (Complete In Triplicate) <br /> Application is hereby made �to the San Joaquin Local Health.. District fora permit to construct <br /> and/or install the work herein described. This application, is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the. San.Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I . ( CENSUS TRACT <br /> Owner's Name EPhone <br /> Address City J . <br /> Contractnr',�~-NameILIr ense L�. . '� Phonxz <br /> -TYPE OF WORK (Check) : NEW WELL /Z;r-�DEEPEN /� RECONDITION / / DESTRUCTION /- _ <br /> PUMP INSTALLATION UMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: ` 'SEPTIC TANK -Y- SEWER LINES_ . ; . _PIT PRIVY <br /> SEWAGE DISPO AL' FIELD CESSPOOL/SEEPAGEaPIT OTHER <br /> PROPERTY,LINE PRIVATE DOMESTIC WELL. - PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE-!DF.. WELL'S * ' t--'�' .-..:CONSTRUCTION SPECIFICATIONS <br /> Industrial „ Cable” Tool Dia. of Well Excavation <br /> mestic/private Drilled ' Dia. of Well Casing <br /> C <br /> Domestic/public Dr%n- Gauge of Casing <br /> L-----Irrigation Grave l;�Pack Depth of Grout. Seal ( <br /> Cathodic Protection otat:,y <br /> � e--of- Grout, s5 <br /> # � <br /> Disposal . .,._ `� OtYier Other Information <br /> Geophysical - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ��� _ <br /> Type` of Pump _ H.P. <br /> �PUMP REPLACEMENT:__ 4,/ / 5tat�e�Work. �3one,�.,f - ~--�•: �-�- <br /> PUMP '.REPAIR: / /} State Work Done <br /> — I <br /> DESTRUCTION OF WELL: Well, Diameter Approximate Depth <br /> i. 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 ]SAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. . The above <br /> c information is true to the',best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU D A FINAL INSPECTION _ <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> !� FOR DEPARTMENT USE ONLY <br /> i PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE / <br /> { ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E✓L DATE e, <br /> a <br /> 077 ' 2M ) <br /> t E 'H-1426 Rev. - I-74 - __ <br />