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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EO 20F-FTCE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 74 ' <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 Phone T5E-06W <br /> Address a City <br /> Contractor's Name (�4 License # LGax Phone y,1,? 6"?7 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/y DEEPEN/% RECONDITION /_/ DESTRUCTION /77PUhel/SALLATION / / PUMP REPAIR / / PUMP REPLACEMENT y� <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIE ON t_`0 <br /> Industrial, Cable Tool Dia, of, Well Excavation <br /> Domestic/private Drilled A -Dia, of Well Casing �'✓. ` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation, Gravel Pack Depth of Grout Seal t <br /> Cathodic Protection Rotary : Type of Grout ' <br /> Disposal Other Other Information �L. <br /> Geophysical Sur�ace' Seal Installed B <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP '.REPAIR: / / State Work"Done <br /> e <br /> DESTRUCTION OF WELL: Well Diameter "`'_ + Approximate Depth <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 DistriVCt a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use.. The above <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTIQN <br /> PRIOR TO GROUTING ANV AOFINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE-) t <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I ! <br /> APPLICATION ACCEPTED BY_K_W_L= DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE T INSPECTION PH IO <br /> /FINAL INSPEC <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 -,. 1177 -. 2M , <br />