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SAN JOAQC?IN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> }: A Telephone: (209) 466-6781 (/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �a [� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �4 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 6'I�tnc-t� .c�-t%t� - CENSUSL�TRArCT p <br /> Owner's Name3 PhonLjej e T to~ / 0 <br /> Address � �/ �h�c�t City <br /> Phone <br /> Contractor's Name License ljG 3 7 3 <br /> TYPE OF WORK (Check): NEW WELL/ 7 DEEPEN '/? RECONDITION /? DESTRUCTION /_7PUMP INSTALLATIONt_/_/ PZXMp REPAIR.O, PUMP REPLACEMENT / <br /> Other <br /> r <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 Seal <br /> Cathodic Protection Ratary� Type of Grout <br /> Disposal Other Other Information <br /> Gegphy-s .cal <br /> Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump '--' H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> + <br /> Approximate Depth <br /> DES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and 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 DAXS <br /> after completion of my work on a new -dell, 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 s true to the est of my.. wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING AND F AL INSPEgION. <br /> SIGNED TITLE <br /> i <br /> W: PLAN 'ON RSE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �. DATE 2-z 7 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:,. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTTOK °.: <br /> INSPECTION BY . DATE INSPECTION BY —)u, DATE 3 <br /> V76 . <br /> E H 1426 Rev. 1-74 <br />