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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 7 <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 /> JOB ADDRESS AOCATION +��� 9g CENSUS TRACT <br /> Owner's Name Phone 36 j^- s rp ' <br /> OF V <br /> Address 11 <br /> City <br /> Contractor's Name /� License #«2-3�VPhone3lohq <br /> ,34i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/_/ RECONDITION DESTRUCTION /7 <br /> � <br /> PUMP INSTALLATION / / PUMP REPAIR '_PUMP REPLACEMENT /-7 <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 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 Grdut <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done. <br /> y <br /> PUMP .REPAIR: State Work Done E \ ^ <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> �.) <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is,,tirue to the best of- knowledge and belief. I.WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU D A I INSPEmy ON. <br /> SIGNED TITLE ;X.*� <br /> RAWPL'T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY LX <br /> PHASE I <br /> APPLICATION ACCEPTED BY �, Awl DATE 40:: + <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPZJMON PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /p -,x'77 <br /> E H 1426 Rev. 1-74 376 2M <br />