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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Jam' -v 7i <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 i. <br /> County Ordinance` No. 1862 and 'the Rules and Regulations of the San Joaquin Local Health District. l <br /> JOB ADDRESS/LOCAONCENSUS TRACT <br /> Owner's Name I ',APhone <br /> Address OCity " <br /> Contractor's Name License 0 _ Phone <br /> TYPE OF WORK (Check) : NEW WELL_ DEEPEN /_/ RECONDITION / / DESTRUCTION /-7J' <br /> PUMP INSTALLATION / / PUMP REPAIR/I / PUMP REPLACEMENT /-7 .� <br /> Other / / i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE JIT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD #./t C SSPOOL/SEEPAGE PIT OTHER_ y <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL j <br /> INTENDED USE TYPE OF WELL lj�, j CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool �vl( . Dia. of Well Excavation , <br /> f '� �D°mestic/p,rivate Drilled ' Dia, of Well Casing <br />{! V Domestic/public Driven [ Gauge sof Casing <br /> Irrigation Gravel Pack Depth ofrGrout Seal <br /> Cathodic Protection Rotary Type of. Grout Q i <br /> Disposal i' Other Other 'Information <br /> Geophysical �--'S-urface-"Seal Installed By: <br />'f PUMP INSTALLATION: ,�� Contractor y{` ' <br /> Type of Pump, ` H.P.i zj <br /> PUMP REPLACEMENT. ' /, / -State-4 46rk Done <br /> PUMP .REPAIR: I; / / `state Work Done <br /> ( o. as. '*f, <br /> DESTRUCTION OF WELLi: Well Diameter Approximate Depth <br /> Describe' Material and Procedure <br /> T hereby agree to comply with+all laws and regulations of the San Joaquin Local Health Distkict <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 'k-est of my knowledge and belief. I WILL C44L FOR A GROUT INSPECTION <br /> PRIOR TO GRMIDIG ANV A F1 L j SPECTION. <br /> SIGNED TITLE <br /> (1AAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I[ <br />,APPLICATION ACCEPTED BY �` ,. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ' INSPECTION BY li DATE INSPECTION BY DATE X 7--'7p <br /> -74 <br /> E H 1426 Rev. Z <br />