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SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> i <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. t }�4f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) "T <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION ��� l+S�� <br /> Phone gSrr' <br /> Owner's Name <br /> City <br /> Address <br /> T �A'M License # Phone <br /> Contractor s Name <br /> i <br /> IE <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / I RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR I / 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 ' r TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial i, . .. Cable Tool Dia. of Well Excavation <br /> Domestic/privatet , _ �Dril.led Dia. of Well Casing . Q <br /> Gauge a of Casing <br /> Domestic/public p 4�,D. �.e.r ven j(`� g <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 /> �)h <br /> PUMP INSTALLATION: Contractor r <br /> Type rof Pump" H.P. <br /> i <br /> D <br /> PUMP REPLACEMENT: . 4 <br /> / // tate rk one — <br /> tiWo <br /> �:. State Work D <br /> PUMP .REPAIR: ,, /' / one <br /> Af X Q/ Approximate Depth <br /> F W - <br /> ES-TRUCTION OF '' Well Diameter � f <br /> Describe Material## nd Procedure O <br /> d' <br /> all laws ari ire ulations o the San J ca ea th District <br /> I hereby agree to comply with g <br /> and the State of California pertaining to or`�regulating well const act o Wit n IFTEEN DAYS <br /> after completion of my work on a near well',�I- will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify threm-, before putting the -well in use. The above <br /> information-is..true�to"-thia.bes-t-of my-knowledge hand belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AND A FINAL INSPECTION. <br /> f TITLE <br /> SIGNED <br /> DRAW- PE T PLAN ON RE FRSE SIDE) <br /> -� - FOR DEPARTMENT-USE ONLY <br /> } PHASE I <br /> j APPLICATIOACCEPTED BY lNa DATE <br /> ADDITIONAL COMMENTS: : <br /> PHASE II.:G OUT .INSPECTION PHASINSPECTION . <br /> INSPECTION BY DATE INSPECTION B DATE �d" 6 <br /> 3/76 2M <br /> E H 1426 Rev. 1=74 <br />