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SAN JOAQUIN LOCAL]HEALTH DISTRICT <br /> FOK,'OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-"'lam <br /> G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In' Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instal, the work herein described. This Application is made in compliance with San Joaquin <br />- County Ordinance No. 1862 and theRu sad Regulations of the San Joaquin Local Health District. <br /> r /W <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Name Phone . <br /> Address Q-7 City ' <br /> Contractor's Name Phone <br /> Linens .3 ` <br /> TYPE OF WORK. (Check) t-�`NEW WELL;/�EEFEId�/? RECONDITi©N�/_�'DESTRUCTION <br /> �~{ PUMP INS'T'ALLATION ���UMF REPAIR /� PUMP REPLACEMENT % � <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD V CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Tool Dia. of Well Excavation <br /> --Ac=--Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven E. Gauge of Casing <br /> Irrigation r �. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ° _ Rotary Type of Grout <br /> Disposal - Other Other .Information E <br /> Geophysical, x Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type'.of PumpZZ <br /> ^-• H.P. <br /> PUMP REPLACEMENT: / / State Work Done 11 <br /> PUMP (REPAIR: / / State Work-Done- <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> ,t <br /> s <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 on a new well, I willfurnish 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 ANAL CTION. 'I <br /> SIGNED " TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY rr� <br /> PHASE i �t I <br /> APPLICATION' ACCEPTED BY �# DATE ' <br /> ADDITIONAL COMMENTS: k <br /> PHASE Il GROUT INSPECTION PHASE III FINAL INSPECT( N <br /> INSPECTION BY DATE M- INSPECTION BY �s f <br /> DATE P Jj ?� i <br /> E H 1426 <br /> Rev. 1-74 1:/7K 9M <br />