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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton Calif. <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 <br /> (Complete In ) <br /> Tri licate 7 <br /> Triplicate)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 +' <br /> CENSUS TRACT <br /> Owner's Name T D � �` <br /> Phone Jb - 7 <br /> Address City <br /> Contractor's Name License Phone <br /> 4 i <br /> TYPE OF WORK (Check) : NEW WELL/7 vD�3EPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION,_A4 PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT P?RIVY <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 ExcavationI <br /> Domestic/private Drilled Dia. of Well dasing 4� <br /> Domestic/public .�` _ <br /> Driver Gauge of Casing � <br /> `^;Irrigation i Gravel Pack Depth of Group Seal <br /> 4 <br /> --__Cathodic Protectiori Rotaryt Type of Grout <br /> Disposal; Other �;; Other Information <br /> Geophysical 1'i", <br /> Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor <br /> -.* r, o .P. Z� <br /> Type of Pump g <br /> k ; � Staten N <br /> PUMP:REPLACEMENT: /i / Work bone z <br /> PUMP .REPAIR: J// State Work Done __ �_ __ ._• _ <br /> ' i <br /> DESTRUCTION OF WELFd ) Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ith all laws and regulations of the Sari Joaquin Local Health District <br /> I hereby agree to comply, w <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 District a j <br /> WELL DRILLERS REPORT of the well and notify them before putting 4hk well in use. The above <br /> information is tru to the best of my knowledge and belief. I WELL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN D Ak �INAI NSPECTION.j <br /> / <br /> SIGNED TITL <br /> i „ DRAW pt7 T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY V DATE -, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N PHASE III/FINAL INSPECTION <br /> INSPECTION BY e,/j - DATE 'z/ i; INSPECTION BY DATE Q <br /> E H 1426 Rev. 1-74 _ 3/76 2M <br />