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SAN JOAQU;IN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif, <br /> Telephone: (209)' 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.?7_,11 A- <br /> 1 <br /> THIS PERMITEXPIRES1 YEAR FROM DATE ISSUED Date Issuedr <br /> (Complete In Triplicate) <br /> Application is Aereby trade 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 <br /> G/ i�-47C CENSUS TRACT <br /> Owner's Name <br /> Phone - <br /> 1' ► <br /> Address f, <br /> V- City <br /> Contractor's Name t License lC n Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN / / RECONDITION /' / DESTRUCTION /-7 <br /> PUMP INSTALI,ATTON— LFI'PUMPfREPAIR / / PUMP REPLACEMENT /-7 <br /> Other / 7 — <br /> DISTANCE TO NEAREST.: SEPTIC�TANK <br /> -� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE. - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE rTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _.�"' i Cable Tool - Dia, of Well Excavation i �I <br /> Domestic/private ` Drilled' Dia, of Well Casing \ <br /> Domestic/pithlic •: ..'Driven ---., Gauge of Casing;- {�E <br /> Irrigation Gravel' Pack Depth of Grout Seal <br /> Cathodic Protection ,` Rotary Type of Grout <br /> Disposal Other Other Information - <br /> Geophysical , <br /> Surface Seal Installed By: * E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.F. r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / State Work Done y <br /> DESTRUCTION OF WELL: Well Diameter � <br /> Approximate Depth <br /> Describe Material Fd Procedure <br /> I hereby agree to comply with all 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 onla 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€. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR9UT,1jqG ANDA INAL S <br /> VT Ip3. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: g , <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /!/ INSPECTION BY DATE -] <br /> E H 1426 Rev. 1-74 1 1177 2M <br />