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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> E ? Telephone: (209) 466-6781 �i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Ia 'r,;�,Sl <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 install the work herein described. This application is made in compliance with San Joaquir <br /> ' County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address ' <br /> ti City � <br /> i w <br /> Contractor's Name Licensed JkSVPh4ne4 3K <br /> f TYPE OF WORK (Check) : NEW WELL /% DEEPEN RECONDITION /_/ DESTRUCTION /`7 <br /> PUMP INSTALLATION /Z?�: PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> :7=7 / <br /> T: a <br /> TANK �_f SEWER LINES , PIT PRIVY . <br /> � DISPOSAL FIELD f� CESSPO L/SEEPAGE PIT OTHER <br /> TY. EINE r` PRIVATE DOMESTIC-WELL PUBLIC` DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well '_Excavation [a <br /> Do Cable <br /> Drilled Dia, of -Well Casing <br /> Domestic/public Driven Gauge of,'-.Casing .� 5 <br /> Irrigation NGravel Pack Depth of-Grout .Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical - <br /> Surface deal Installed D <br /> PUMP INSTALLATION: Contractor u ZI <br /> - Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done' . <br /> f PUMP '.REPAIR: /% State Work Done <br /> DESTRUCTION 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 /> 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 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 ofmy knowledge'-and belief, I WILL CALL FOR A GROUT INSPECTION � <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> € (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I/ INAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE g <br /> E H 1426 Rev. , 1-74 6/77 2M <br />