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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO h OFFICE USE: 160i E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466•-6781 W <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Date Issued <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 tan 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 /> . !� Phone <br /> Owner's Name e_2Za <br /> Address "'= City <br /> or <br />'4r License # '2`. Phone ^ ' <br /> - <br /> : <br /> Contractors Name <br /> , $. <br /> TYPE OF WORK {Check): NEW WELL 117 ,DEEPEN/? RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /� PUMF REPAIR /�PUMP REPLACEMENT r7 a4 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIKES 1- PIT PRIVY <br /> ' SEWAGE DISPO�IELD - 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 A .s <br /> Domestic/private . Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal' <br /> ..t ` ' <br /> Cathodic Protection ,�5;^ Rotary Type of Grout <br /> Disposal Other Other Info"rmatioa-� <br /> Geophysical. 'Surface"Seal',I"'1 gilled-B '. <br /> PUMP INSTALLATION Z Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP,`.REPAIR: ,L- State Work Done { <br /> 2L TRUCTION 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING D FI INSPECTION. <br /> k .SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE . -�--FOR 2MSRTMENT USE ONLY <br /> PHASE I .- �..z ,�..._. <br /> APPLICATION ACCEPTED BY - ww DATE `"/ l7 (_- <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PHASE ,414/FIIJAL INSPECTION <br /> INSPECTION BY DATEINSPECT ION BY DATE <br /> t: .!>.Z_H 1426 Rev. 1-74 - <br />