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' SAN JOAQUTN LOCAL HEALTH DISTRICT <br /> FOE-r-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: - (209) 466-6781 IS� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT`EXPIRES 1. YEAR FROM DATE ISSUED Date Issued / /'7, f <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. 1862 and the Rules and Regulations of .the San Joaquin Local .Health District. <br /> I <br /> JOB ADDRESS/LOCATION 3 0,79 <br /> CENSUS TRACT : . - <br /> Owner's Names 1 v j7 � Phone <br /> Address 3��l ��C? �tt City- <br /> License <br /> Contractor's Name License # .2 dl3Phone S <br /> TYPE OF WORK (Check) : NEW WELL ."/ DEEPEN / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATIONPUMP REPAIR / / PUMP REPLACEMENT <br /> Other 1_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK�j Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL-SELO PUBLIC DOMESTIC WELL <br /> 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 _ � V <br /> Irrigation 3( 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 /> Pt <br /> PUMP INSTALLATION: Contractor o /i1� Il'`` 1" 77~rS7� <br /> Type of Pump 6V �L H.P. 20 <br /> t PUMP REPLACEMENT: / / State Work Done <br /> EI PUMP .REPAIR: / / State Work Done <br /> er <br /> DES-TRUCTION OF WELL: Well Diameter c2 Approximate Depth <br /> Describe Material and Procedure <br /> k <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 /> k 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D AL NSPECTION. <br /> --SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -Z - /` 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ;- 2M <br /> E H 1426 Rev. - 1-74 <br />