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/ SAN JOAQUIN LOCAL 14EALTH DISTRICT <br /> I FOR OFFICE USE: 1/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I <br /> Telephone: (209) ,466-6781 <br /> I Ij APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . D� <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 OrdinaLe. No. 1862 and the Rules and Regulations of the.; San Joaquin Local health District. <br /> d� p Al <br /> JOB ADDRESS/LOCATION [ /s , �jsrr7�.�� c3�,BtJ, RACT <br /> j Owner's Name _ �,: ,r� Phone3 <br /> l IN <br />,I Address I� ,r <br />{ City <br /> Contractor's Name License 0;�1^3 2 Phone <br /> 3� <br /> TYPE OF WORK (Check):- NEW WELL / / DEEPEN RECONDITION / / DESTRUCTION /_7 <br /> II PUMP .INSTALLATION / / PUMP REPAIR A.S�/" PUMP REPLACEMENT /-7 <br /> II Other'/ / <br /> DISTANCE TO NEAREST: SEPTIC+TANK SEWER-�LTNES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE,$=POOL%SEEPAGE PIT OTHER <br /> PROPERTYILINE - PRIVATE I3OMESTIC WELL PUBLIC DOMESTIC WELL <br /> -<:: ' INTENDED USE TYn-QF'yaI,------- CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable 'Tool Dia, of Well Rxcavation <br /> Domestic/private Drilled I Dia, of Well Casing <br /> Domestic/public - � Driven y,.r Gauge of Casing - _- <br /> Irrigation 1 Gravel Pack�J,� Depth' of Grout! Se'al.,\'\ <br /> Cathodic Protection .1 RotaryType of Grout ' L + <br /> Disposal �� Other I: Other Information �1 <br /> Geoh sinal i <br /> P Y � ' t( Surface Seal installed By: _-- - <br /> ' <br /> PUMP INSTALLATION: Contractor 'LJ <br /> �I Type of Pump A `_ r H.P. <br /> I � <br /> PUMP' REPLACEMENT: / / St6te Work Done ` <br /> 4 PUMP .REPAIR: St to Work Donk 1 . <br /> I DESTRUCTION OF-WELL: ^5 Well Di meter ; Approximate Depth <br /> Describ Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Statellof 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 DRILLERS11REPORT of the we l ,and notify them before putting the well in use. The above <br /> information is true to the becif- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT' AN A FI ECT ION. <br /> SIGNED TITLE <br /> II I�AW PI, T PLAN ON RE EkSE SIDE)- —' '� ': <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2 <br /> - -- <br /> ADDITIONAL COMMENTS: <br /> s PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> k ' INSPECTION BY DATE INSPECTION BYDATE -lo- �-? <br /> E H 1426 �� Rev. 1-74 3/76 2M <br />