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.. c .. {—�. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � 7/2,4/7 <br /> FOBrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. _ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Gc/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued 7y <br /> ' (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instar, 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 _YLAS r /D U / � CENSUS TRACT <br /> Owner's Naive ®�' Phone <br /> Address City;, '/ h <br /> Contractor's Name � 5-& _ License <br /> TYPE OF WORK (Check): NEW WELL 4V DEEPEN 1_7 RECONDITION /? ME <br /> DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACENT f7 <br /> Other /% -- <br /> DISTANCE TO- NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP $0 AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS { <br /> Industrial Z�__ Cable fool Dia. of Well Excavation 1411 <br /> !/ Domestic/private Drilled Dia. of Well Casing v <br /> ! _ Domestic/public Driven Gauge of Casing <br /> i 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 '4 <br /> PUMP -REPAIR: /7 State Work Done <br /> E&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 t <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS i <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-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING --A FINAL,INS ECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE �� <br /> PHASE I 72,.7 ( L - 44 FOR DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHA II ROUT I PECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY �� DATE o - INSPECTION BY DATE <br /> i <br />� E H 1426 Rev. 1-74 tt — <br /> cs �V �!/` <br />