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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO) OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. e <br /> 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 7�f <br /> (Complete In Triplicate) <br /> Application is -Aereby 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 �V S 2i, <br /> � CENSUS TRACT � <br /> Owner's Name L, i Phone ' :F,(. <br /> Address /U C iQl { a �r <br /> City L <br /> .s ' <br /> Contractor's Name � s 6 <br /> Jc�g Licend P' Phone? Y <br /> _ _ t <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / EPEN /� RECONDITION /_ DESTRUCTION 1-7 � <br /> PUMP INSTALLATION 4. ;t_ PUMP REPAIR /% PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEfPPIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL P.UBLIC 'bOMESTIC WELL a� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We-Il Exp va ation <br /> Domestic/private Drilled Dia, of.Wel1 Casin <br />-L7:_ omestic ublic , g -- <br /> /P Driven Gauge?of Casing <br /> Irrigation Gravel Pack Deptli/o,f Grout �Seaiy. C)Cathodic Protection totaryType ,of. Grout <br />—Disposal `"—r �- - . <br /> Other -�.,, Other Information <br />—Geophysical <br /> ' Surface Seal Installed By: <br /> PUMP -INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT• _ Ilk/ / State Work"Done _. <br /> PUMP--12E-PAIR:` _ : - .,_ - / / State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approitimate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sao, 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 Lo al 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 CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL IN ECTION. <br /> SIGNEDry TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �• <br /> APPLICATION ACCEPTED BY ' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE /,/ <br /> E H 1426 Rev. 1-74 ; 1177 _ 2M"' <br />