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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR OFFICE 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?r�� <br /> (Complete In Triplicate) <br /> Application is hereby made toI the San Joaquin Local Health District for a permit to construct <br /> Joaqu <br /> and/or install the work. herein described. This application ismade <br /> JoaquinpLocaleHealthSan Districtin <br /> County Ordinance No. 1862 and,lthe Rules and Regulations of the San <br /> CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION S 1 � <br /> v A Phone,36- <br /> �`• 7 <br /> Owner's Name ' <br /> 7i j City l� <br /> Address <br /> License #/c_ � Phone <br /> Contractor's Name <br /> i <br /> TYPE OF WORK (Check) ; NEW WELL /� DEEPEN '/ / RECONDITION_/-7 DESTRUCTION / <br /> PUMP INSTALLATION I I PUMP REPAIR / I PUMP REPLACEMENT ; <br /> Other.�/ I <br /> ��� SEWER LINES PIT PRIVY <br /> f DISTANCE TO NEAREST: SEPTIC TANK �1 <br />', SEWAGE.�DISP05AT, FIELD CESSPOOL/SEEPAGE PIT OTHER JJ .. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ,TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of 'Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> t <br /> Type of Grout <br /> Cathodic ProtectionRotary yP <br /> [ Disposal ;. Other _ Other Information <br /> Geaphy_sical ,� r Surface Seal Installed B <br /> -.. ,,nn <br /> PUMPINSTALLATION: Contractor N� r <br /> P. <br /> Type of Pump <br /> s _ State Work Done <br /> pump REPLACEMENT: <br /> t <br /> � . State-Work Done <br /> ,P_LTMI�.:REP.AIR:..-a„��: -...�_ / -/ <br /> DESTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notify well in use. The above <br /> them before putting the . <br /> information is true`'tothe-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR IN AND FIN IN5PE ON. <br /> l SIGNED TITLE ,i, <br /> W PL T' PLAN ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ir DATE � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASF, I IIFI NAL INSPECTION- <br /> PHASE II GROUT INSPECTION INSPECTION B DATE <br /> INSPECTION BY DATE <br /> ` 3/76 2M <br /> -._E H 1426 Rev. 1-74 <br />