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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k FOArO ICE USE: X1601 E. Hazelton -Ave. , Stockton, Calif. <br /> j Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued76� <br /> - ! (Complete In Triplicate) <br /> Applieation 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 h <br /> to d Phone <br /> Address <br /> S r City . <br /> Contractor's Name 12 License # Lf;3 phone <br /> __..� <br /> ;TYPE OF WORK (Check): NEW WELL/? DEEPEN ./7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENTly <br /> Other I/% <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 WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool_ Dia. of Well Excavation �I <br /> r _ Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public j Driven Gauge of Casing ` 1 <br /> Irrigation ! Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary Type of Grout <br /> t Disposal Other Yh <br /> Other Information ., <br /> Geophysical. <br /> Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 s <br /> PUMP-REPLACEMENT: /fC/ State Work Done ' �[- �/21a�xa�/� �I , ' 7�yr�,�,�L►� <br /> PUMP '.REPAIR: <br /> /7 state work Dane <br /> ES•TRUCTION OF WELL; I y <br /> We11 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on .anew well, I will furnish the San Joaquin Local Health-District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well in use.. The above <br /> information is true to- the best of my. ;�wledge belief. I WILL CALL FOR A GROUT INSPECTION <br /> 4PRIOR TO GRO G AND A FINAL °INSPECT <br /> SIGNED TLE ; <br /> � . {DT P ON SE SIDE <br /> .PHASE I FOR DEPARTMT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS ECTION PHASE 1114YINAL INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY DATE C <br /> 1 E H 1426 Rev. 1-74 <br /> .. Jw <br />