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JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi UA- <br /> OFFICE USE: /' 1601"*1. Hazelton Ave. , Stockton, Cali. <br /> V 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 Joaluin <br /> County Ordinance No. 1862 and Che Pules and Regulations of the San Joaquin Local Health Distri t. <br /> JOB ADDRESS/LOCATION ���Z F /���•/ � CENSUS TRACT <br /> � - <br /> Owner's Name ' /j Iy ��� C'SG Phone �� .��? v <br /> Address City <br /> Contractor's Named License li Phoneme ' <br /> e,G } <br /> TYPE OF WORK (Check) : NEW WELL { / DEEPEN / RECONDITION /_7 DESTRUCTION /_ / <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �G <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 m <br /> Industrial Cable Tool Dia. of Well Excavation `1. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Iomestic/public Driven Gauge of Casing <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump j H.P. <br /> PUMP REPLACEMENT: / State Work Done r' re <br /> PUMP .REPAIR: / / State Work Done <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 Distric <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric a <br /> WELL DRILLERS REPORT of t well and notify them before putting the well in use. The above <br /> information is true to best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO G A FINAL INSPECTION. <br /> SIGNED 2L�vG �- TITLE 1_1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _c `r -h -- DATE ! V.- <br /> ADDITIONAL <br /> /ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D,pTE L -23, <br /> H 1426 Rev. 1-74 -7�9m <br />