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f/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FOR 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 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. i <br /> a <br /> JOB ADDRESS/LOCA T ON 71� Lc1 CENSUS TRACT <br /> 9 Owner's Name Phone_ <br /> Address City <br /> Contractor's Name License IIAL�23 Phone R r i <br /> `5 <br /> i' <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN RECONDITION /_/ DESTRUCTION /7 <br /> ----- -�---- .--PUMP INS�Ai-LAT-ION-=/_% -::P�Il'�'REP-AI-R4-���P-UW--REP-LACEMENT-/- <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 WELD, `P� CONSTRUCTION SPECIFICATIONS <br /> r Industrial ; Cable 'Tog1 DUa..1 of Well Excavation <br /> - Domestic/private Drilled--,,,' iF Dia. of Well Casing <br /> Domestic/public I Driven '`J�, auge-of Casing <br /> Irrigation Gravel Pack f` Depth. A Grout Seal <br /> Cathodic Protection Rotary fy Type of" Grout 3 <br /> Disposal i Other 0 her` Ihformation <br /> Geophysical 'Surf ace_Seal Installed_By: <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of[ Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / ' State Work Done ' <br /> PUMP .REPAIR:" State Work DoneQ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I � , <br /> I hereby agrc o�co ply .?ith �a1l._laws and,_regclatiin <br /> os_.of..the San J,paquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my,work ontra new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we,,11 and notify them before putting the -well in use. The above <br /> information i true to the-best of-3my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO)TYINGAND A AL INSP CTION. <br /> SIGNED <br /> TITLE <br /> i !2A�_(DRAWPMT PLAN ON RE TERSE SIDE) � ' � <br /> y FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASE I /,FINAL INSPECTION <br /> 1 'w <br /> INSPECTION BY DATE INSPECTION BY DATE IQ`IS-7G <br /> E H 1426 Rev. -1-74 <br /> 3/76 2m <br />