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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FO'ExOFFICE USE:. <br /> =1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: {209} 456-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA PERMIT Permit No. <br /> THIS' PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued7� <br /> (Complete In Triplicate) ct for a permit <br /> o construct <br /> Application is hereby made to%the San Joaquin Local Health Distrmade in compliance twith San Joaquin <br /> and/or install the work herein described. This application i <br /> County Ordinance' No. 1862 andl`the Rule and Regulations f the San Joaquin Local Health District. <br /> CENSUS TRACT_ <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name <br /> l '3 City � <br /> Address <br /> License # ;M!�t7Phone j <br /> Contractor's Name ' . J �� f <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN / / RECONDITION / / DESTRUCTION IT . <br /> PUMP INSTALLATION / I PUMP REPAIR I I PUMP REPLACEMENT <br /> Other '/ / <br /> i <br /> DISTANCE TO NEAREST: SEPT15.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 <br /> TYPE OF WELL -CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable....Too1: Dia. of Well Excavation <br /> Domestic/private Drilled J :Dia. of Well Casing ( <br /> Domestic/publicDriven- - - Gauge' Of Casing W <br /> Irrigation . s _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection .4k Rotary Type of Grout , <br /> Disposal j7- Other Other Information <br /> Geophysical <br /> Surface Seal Install d B <br /> ION: Contractor <br /> PUMP INSTALLATION: H.P. <br /> TYPe#of Pump <br /> PUMP REPLACEMENT: /�/ State Work Done -nil <br /> ✓ � <br /> PUMP .REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth _ <br /> Descxibe Material and Procedure <br /> Health District <br /> I herebyagree to comply with all laws and regulations of the San Joaquin Local <br /> and the State of Calif orniapertaining 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 District a <br /> WELL DRILLERS REPORT of thewell 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 C FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING IN IN PECTION. TITLE <br /> SIGNED �. <br /> L W PT;'T PLAN QN RE LRSE SIDE) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 74' <br /> r APPLICATION ACCEPTED BY G> <br /> .ADDITIONAL COMMENTS: PHASE II /FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY W DATE y 2c <br /> INSPECTION BY 1 DATE <br /> 376 2ME H 1426 Rev. <br /> 1-74 , . . <br />