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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB!'OFF'ICE 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 <br /> (Complete In Triplicate) <br /> Application is hereby made Ito the San Joaquin Local Health Distiict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> t <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner c s Name Phone 2 5F L-_2 .36 <br /> � <br /> i <br /> Address © � City T �`'•�, <br /> { y <br /> Contractor's Name _ �. _. ,. n License #/� 23 Phone �- - <br /> k TYPE OF WORK Check) : NEW WELLDEEPEN- ION / ESTRUCTION /7 <br /> PUMP INSTALLATION / j PUMP REPAIR & PUMP REPLACEMENT /_7 T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY p <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE._-- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE Y wTYPE f3E: WELL_�...- ';4 ._ _ ,,.._ 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 Grout <br /> E Disposal Other Other Information C <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �, V <br /> T e of Pump <br /> yP H.P. <br /> PUMP REPLACEMENT: .. i <br /> ; State Work bone <br /> PUMP .REPAIR: State.,Work`.Done:Pte- <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth T - <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 puttiing 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 /> i PRIOR TO GROUT2NG AND A FAL INSPECTION. <br /> SIGNED TITLE <br /> 1 PLOT PLAN ON REVERSE <br /> PARTSIDE <br /> ' <br /> PHASE I OR DEMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR P IO PHAU TIIJFINAL INSPECTION <br /> INSPECTION BY `DATE INSPECTION BY DATE y <br /> rR E H 1426 Rev. 1-74 1-74 2M <br /> 4 <br />