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`+ SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOROFFICE USE: 1601 E. Hazelton Ave. ,�Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7&1-3 Sz/, <br /> THIS PERMIT EXPIRES 1 YEAR- FROM DATE ISSUED Date Issued- 7� <br /> (Complete <br /> Application is hereby made 'to the San Jo uin Local Health District <br /> r <br /> and/or install the work herein described. This application is made incompliancetwith' Sanuct Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> } <br /> JOB ADDRESS/LOCATION <br /> i' CENSUS TRACT <br /> i Owner's Name - <br /> Phone <br /> Address <br /> - <br /> City <br /> Contractor's Name - - <br /> License !i -1�la�� Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEL/-7 DEEPEN /-7RECONDITION /_7 DESTRUCTION' <br /> PUMP INSTALLATION / PUMP REPAIR /-7—Pump REPLACEMENT— <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTTC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial t Cable Tool Dia. of Well Excavation \ <br /> 3 Domestic/private Drilled ; <br /> Domestic/public Dia, of Well Casing <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout' <br /> -Disposal i Other Other Information I <br /> Geophysical Surface Seal Instal e B t <br /> PUMP INSTALLATION: Contra� i <br /> ctor 41 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done ''`'��, � ;[ <br /> PUMP 'REPAIR: State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter k <br /> Approximate Depth x <br /> Describe Material and Procedure ------ ` <br /> x <br /> I hereby agree to comply withiall 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 s <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 <br /> PRIOR TO GR TING A INAL `I1VgpECTION. CAUFORA GROUT INSPECTION <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 5� z 7L� <br /> ADDITIONAL COMMENTS: p <br /> PHASE II GRO ' SPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />