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SAN JOAQUIN LOCAL't'EALTH DISTRICT <br /> FOE OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � � ! N p � � ! CENSUS TRACT . <br /> Owner's Name d. era rt Phone <br /> Address i✓C.�t 1 �( i Cit <br /> Contractor's Name a4. License #., 7�Phone <br /> 4a <br /> TYPE OF WORK (Check) : NEW WELL -/7 DEEPEN '/_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR -&-7 PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> K Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 'tom <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 eofPu ... <br /> Pump '_ 6 � H.P. <br />'PUMP REPLACEMENT / / State Work Done <br /> PUMP ,REPAIR: 1144 State Work Done <br /> I]ES•TRUCTION 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 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 o kmy.kn w-1 dge a d belief. I WILL CALL FOR .A GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL INSP I <br /> SIGNED -,.TITLE <br /> D WP= PLAN ON ERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE ' 3 75 <br /> ADDITIONAL COMMENTS-. <br /> PHASE I - ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r h/75 2M <br />