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f dp SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: •j 1601 E. Hazelton -Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f 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. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �� � -- Phone <br /> I Address � n _ City <br /> Contractor's Name 14114,41Z / [[//� Licens `qe6'-V,> Phone - <br /> j + <br /> -i <br /> TYPE OF ;WORK (Check) : NEW WELL DEEPEN/_% RECONDITION / / DESTRUCTION /- <br /> PUMP INSTAL TION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other E'/ / <br /> C <br /> DISTANCEiTO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation V <br /> � ol�mestic/private Drilled Dia. of Well Casing <br /> Domestic/public a Driven Gauge of, Casing /,2_ Awl <br /> Irrigation Gravel Pack Depth of.-Groumt Seal•. --- . <br /> Cathodic Protection m Rotary Type of Grouter./ _. S' fyJ�� / '•'— <br /> Disposal Other Other Information ; <br /> Geophysical ,. _Surfac�eal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type o.f�Pump H.P. <br /> PUMP REPLACEMENT: / / State Work. Done <br /> PUMP .REPAIR: / ] "State Work;Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> p P <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'mconstriuction. Within FIFTEEN DAYS <br /> , after completion of my work on. a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we11-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 /> PRIOR TO GROUT NG D A FT NAL�, INSPECTIO . <br /> SIGNED <br /> TITLE <br /> DRAW.MPLOT' PLANmON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I r- <br /> APPLICATIONmACCEPTED BY___ ... � ; DATE <br /> ADDITIONAL COMMENTS: - -`" <br /> __.. <br /> P S . II GROUT INSPECTION PHA I/ ,INAL INSPECTION <br /> .(y <br /> INSPECTION BY - o— DATE ,S-- j-..7 , INSPECTION BY, ' DATES_-Z6--7') ' <br /> E-'H-1-426, Rev. 1-74 3/76 2M I <br />