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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: I 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 /> pplication is hereby made to the San Joaquin Local Health District for a petnnit to construct <br /> -ad/or install the work herein described. This application is made in compliance with San Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> _JB ADDRESS/LOCATION C% t� J ..t�; ( � •�/�lj? CENSUS TRACT <br /> r,aner's Name � -, ..�` L�- .� �. �` ,� �,�.,:� hone �� -���• � <br /> address / d /Y /'�f . .._ Cityj � . <br /> )ntractor's Name /te� � �.� F1 /Bt C License j,. phone = ' <br /> IPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR /—/ PUMP EPLACEMENT /7 <br /> Other <br /> STANCE 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 C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> W .REPAIR: / / State Work Done <br /> PVS•TRUCTION 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 District <br /> .d the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> meter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT 'the well and notify them before putting the well in use. The above <br /> : .formation is e <br /> tr c to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> -IOR TO GROUT,I RAND„�AF1NA'L'INSPECTION J� <br /> SIGNED 4. ,� �;. TITLE , ` :° �« <br /> ` (DRAW PLOT PLAN ON REVERSE SIDE) t <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE�_� -`-t- <br /> i DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FIN SPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE 2z 7S^ <br /> E H 1426 Rev. 1-74 <br />