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SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone : (209) ' 466-6781 f6�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued D—f --A <br /> (Complete In Triplicate) <br /> Application is hereby made to the San J6aquin 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 /> F <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> AddressP. -. <br /> City <br /> Contractor's Name L License Phone <br /> c ,&2d X32�7y,7 <br /> _ r � <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN _ <br /> RECONDITION / <br /> if _/ / / DESTRUCTION /_7 01 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP/ REPLACEMENT /� '` <br /> Other 1/ <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> _ Domestic/private Drilled Dia.. of Well Casing •• <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel�`'Pack Depth of Grout Sea <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information kZMMME <br /> --" <br /> Geophysical ^ Surface Seal Installed B ; <br /> r <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump <br /> H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done j <br /> k <br /> PUMP '.REPAIR: / / State Work Done <br /> DES•'TRUCTION OF WELL: Well Diameter <br /> 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 <br /> an'd the State of California pertaining to or regulating well ''construct <br /> after completion of my work on' ion. Within FIFTEEN DAS <br /> a new well;; I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before pistting the well in use.. The above <br /> information is rue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROETTAM Amn A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> b (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I DATE <br /> PHASE I GRO T INSPECTION <br /> PHASE I /FINA INSPECTION <br /> INSPECTION BY ;�„ DATES DATE --/ 7P <br /> /�7� iNSPECTION BY-rr <br /> E H 1426c Rev. 1-74 %� S �"'' t 1 ,17-7 `� ,� <br />