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- <br /> _ SAN JOAQUIN LOCAs. HEALTH.DISTRICT <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 ,,a _z <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 l <br /> County '-Otdinance No. 1862 and the Rules and 'Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION U I� CENSUS TRACT j <br /> Owner's Name Phone <br /> Address D 6-ae , <br /> City, � �J <br /> Contractor's Name wLicense # Phone G G S 1 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP 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 CONSTRUCTION SPECIFICATIONS Q <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor „ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . /$C/ State Work Done ,Q; ,. , �� ,_--• L <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ° <br /> Desc'tibe 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 anew 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 INSPECTIOR <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ,�,�,,� TITLE <br /> D6d P PLAN 'ON RE 3tSE SInE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , DATE <br /> E H 1426 Rev. 1-74 3/76 ►��: <br />