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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 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 ;0'-,?- ' <br /> r (Complete In Triplicate) <br /> k 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 /> f County Ordinance No. 1862 and the Rules a Regulations of t)w San 'Joaquin Local Health District. <br /> .SOB ADDRESS/ or <br /> TION O r C US TRACT <br /> Owner's Na Phone <br /> r } <br /> Address496d City' <br /> 1ST Cantractor'e-Na— ' • x -=�.- --=.- Licensed. <br /> TYPE OF"WORK (Check) : `:NEW WELL /? DEEPEN -/-7 RECONDITION � ' DESTRUCTIONf <br /> rPUMP INSTALLATION,:/ / PUMP REPAIR -/� 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 I 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. p ,Surface Seas. Installed By: <br /> PUMP INSTALLATION. Contractor <br /> E 'Type -of Pump H.p. <br /> kG? J�tee.. <br /> � PUMP REPLACEMENT: , 1g�- State Wor - ne <br /> 77-;777777- --77777— <br /> PUMP .REPAIR: / / :State Work Done <br /> &TRUCTION_OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r 4 <br /> F ,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-of. my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROTITING AND A"FINAL INSPECTION. <br /> SIGNED - TITLE ���,,, <br /> ww ` (DRAW PLOT PLAN ON REVERSE SIDE <br /> FPR DEPAPTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED. BY a <br /> DATE <br /> ADDITIONAL COMMENTS: L: <br /> PHASE II GROUT ,INSPECTION P4ASE FINAL INSPEC .ION <br /> INSPECTION BY ;;:.' DATE i '` INSPECTION B DATE <br /> ,r E H 1426 Rev. 1-74 r' h/75 <br />