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SAN JOAQUIN LOCAL HEALTH. DISTRIICT <br /> FOE 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' 3_;4-�) <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/LOCATION _f /_z / _ CENSUS TRACT <br /> Owner's Name 4L 14Phone <br /> Address /' City <br /> ne <br /> eT <br /> Contractor's Name License Pho <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / /� RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR ./—/—PUMP REPLACEMENT /T7 <br /> Other '/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK /lga 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 c----Cable Tool Dia. ,of Well Excavation rf \ <br /> �mestic/private Drilled Dia. of Well Casing °� <br /> Domestic/public Driven Gauge of Casing V <br /> Irrigation Gravel Pack Depth of Grout Seal d V <br /> Cathodic Protection Rotary Type of Grout $ " <br /> Disposal Other Other Information ; <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor X11 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_7 State Work Dona <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 true to the best of my kno ledge and belief. I WILL CALL FOR A GROUT IN CTION <br /> PRIOR TO GRO I AND A FINAL INSPE <br /> SIGNED TITLE <br /> !q,�DkAWPOT PLAN ON REVERSE SIDE ,•, i. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE YLOZ <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 6-z 3 <br /> *E' H 1426 Rev-1-74 3/76 2M <br />