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SAN JOAQUIN LOCAL I ALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave::,A tockton, Calif. <br /> Telephone: , -(209) 466-6781 <br /> VArPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No � � <br /> THIS PERMIT EXPIRES ,I.Y'EAR FROM DATE ISSUED Date Issued <br /> r (Complete•In�Triplicate) , <br /> Application is hereby made to the San Joaquin .Loca1 Realth 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, - - -/,0 CENSUS TRACT <br /> Owner's Name ea /6401-,j s Phone , s"/ <br /> .., <br /> Address City , <br /> S <br /> Contractor's Nam - License # haney--��7L; <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /7 RECONDITION- /-T DESTRUCTION /-7 <br /> PUMP INSTALLATION PR7 PUMP REPAIR / ./ PUMP REPLACEMENT /7 O <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 <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 /> Disposal Other Other, Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> �0 <br /> PUMP REPLACEMENT: / / ,State Work Done <br /> PUMP LU State Work Done <br /> ES:TRUCTION OF WELL: Well Diameter Approximate Depth j <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 ori a new well, I will furnish the San Joaquin Local Health District, 4 <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-well in-use.. The above <br /> ..4 information is true to the-best of my kno ,ledge,an belief. I WILL CALL FORA GROUT INSPECTION <br /> ''PRIOR TOG ING MP A FINAL INSP N: <br /> SIGNED- ITLE <br /> • (D PLOT PUN ON RE RS&'SIDE <br /> ?ORDEPARTMENT USE ONLY <br /> PHASE I , <br /> p APPLICATION ACCEPTED- BYDATE - ¢ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ~E S 1.426 <br /> Rev. 1. 74 1-74 2Mj <br />