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1� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi'OiFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> s4 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 ,-G-_7, <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT �{ <br /> Owner's Name o <br /> Phone / <br /> Address City � `r c� <br /> Jy Coatractor f s Name d/ � �- . � License /f-3 SYS Phone <br /> TYPE,OF.WORK (Check): -NEW;WELL/?---DEEPEN 1-7—RECONDITION /_7 -DESTRUCTION /7 - - <br /> PUMP INSTALLATION Lf� PUMP REPAIR /7 PUMP REPLACEMENT /? <br /> ► ..._. <br /> 17 <br /> DISTANCE TO REAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> 1 1 <br /> Industrial Cable Tool Dia. of Well Excavation v` <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 1 <br /> Disposal. _ Other Other Information xf4 <br /> Geophysical Surface_Seal Installed„By; <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump 42 v H.P. / <br /> P / State Work Done - t✓ /-,. r!',/ � .,_,. ._ <br /> PUMP `.REPAIR:. /-7 State Work Done <br /> PiiiRUION OF WELL:. <br /> We <br /> CTi Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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' s 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 m knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GRO TING D A FINAL _kRSjg . <br /> SIGNED TLEf41`. <br /> RA PLOT PLAN ON REMSE SIDE <br /> FORLap_ USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT Y e DATE a 7 <br /> ADDITIONAL COMMENTS: <br /> ¢ PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION ? <br /> INSPECTION BY DATE INSPECTION BY DATE 6: ; <br /> i <br /> E H 1426 Rev. 1-741-74 2M CPi <br />