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SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS,rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ' <br /> Permit No. z�i_S <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued <br /> I {Complete In Triplicate) - oS 2s'o_ � <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. <br /> This application is :Wade in compliance with San Joa uiu <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 <br /> Phone <br /> Address <br /> City �. c 17JZ). <br /> Contractor's Name <br /> wq f �G=c3 License # hone ,L -,p <br /> TYPB 'OF WORK'(Check): NEW WELL/7 DEEPEN '/? RECONDITION 1? DESTRUCTION /� <br /> PUMP INSTALLATION � PUMP REPAIR /_7 PUMP REPLACEMENT /-7 <br /> Other �/� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ PIT PRIVY <br /> SEWAGE DISPOSAL FIELDsi <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well--E—XC avation <br /> Domestic/private - Drilled Dia. of Well, Casing <br /> IrrigatioDomestic/n <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth: of Grout Seal <br /> Cathodic Protection Rotary 4 �Type of Grout <br /> Disposal Other Other" Information <br /> Geophysical. .. � �~ Surface Seal Installed B <br /> FUMP. INSTALLATION: Contractor <br /> Type of Hemp H.P. <br /> PUMP REPLACEMENT: // State Work Done <br /> PUMP t9HF_"_ R: <br /> 0 State Work Done <br /> J&&TRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> ---------------- <br /> I hereby agree to complywith all laws and regulations of the San Joaquin Local Health District `j <br /> and the State of California pertaining to or regulating well construction. ` 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 well and notify them before putting-the- well in-use.. The above <br /> information is true to the best o£ m knowle a and lief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPE i <br /> SIGNED . <br /> TLE k <br /> T P N REV SE SIDE <br />:PHASE I R DEPARTMENT USE ONLY ; <br /> AFP CATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: , DATE <br /> PHASE II GROUT INSPECTION PHASE ITI FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY <br /> DATE <br /> E H 1426 Rev. 1-74 ( i <br />