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� r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> j Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,72.- / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - /- <br /> h . (Complete In Triplicate) <br /> Application is Aereby made to the Sara 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 CENSUS TRACT <br /> 0 <br /> Owndr's Name i� Phone ' 4-7 . <br /> Address : City <br /> Contractor's Name 2LI License Phone �� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /7 / "l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE -DISPOSAL" FIELD CESSPOOL/S'M E'PIT i OTHER <br /> PROPERTYILINE - PRIVATE DOMESTIC WELL 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 <br /> Irrigation 1 Gravel Pack Depth of Grout Seal .-' <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal d Other Other Information <br />- � Geophys.ical + Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of j Pump H.P. <br /> s <br /> PUMP REPLACEMENT: State Work Done E <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulation's 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 w <br /> information is true to the best of my knowledge and belief. 'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GOETING AND A FINAL=ISPECTIO . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I per' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: j <br /> PHASE II GROUT INSPECTION PHOE FINAL SPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> w 1177 _ 2M17-1 <br /> s <br /> E H1426 Rev. 1-74 <br />