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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE 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 Issued6_,_22_-27 <br /> Lc-x_ }2-- j - _ (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. .1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a CENSUS TRACT <br /> max. <br /> Ownero's Name Phone . <br /> Address , W City <br /> Contractor's Name / r License # Ayjtgzx-Phone <br /> IYPE•OF WORK (Check): NEW WELL/? DEEPEN /7 RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP INSTALLATION 577PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLL' PUBLIC DOMESTIC WELL <br /> F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 /> I. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR.- /_7 State Work Done <br /> SES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agreeyto 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 /> I <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe well in-use.. The above <br /> information is true to the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTOG AIRD A FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -44 DATE _LZ <br /> ADDITIONAL COMMENTS <br /> PHASE -II GROUT INSPECTION P E III kINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE1o�r�--'� <br /> Ift E H 1426 Rev. 1-74 1-74 2M <br /> } <br />