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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160. 1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.' <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Q Phone <br /> Address City <br /> Contractor's Name License #245-741 Phone <.-44,­f9 <br /> -i <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION /_/ ` DESTRUCTION /_ a <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <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 i .TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . j, Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing' <br /> Domestic/public Driven Gauge of Casing f <br /> Irrigation I Gravel Pack Depth of Grout-.!Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information � ! <br /> Geophysical --`- "`surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump - H.P. 1 <br /> i <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter 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 E <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 f <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION R <br /> PRIOR TO GROUPING AND A FINAL INSPECTION. <br /> SIGNED C i a-TITLE` <br /> ;'jDRAW W P PLAN 'ON REVERSE SID ) E <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I i <br /> APPLICATION ACCEPTED BY /y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 'INSPECTION -PHASE II INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> G <br /> E H 1426 Rev. '1-74 3/76 2M. <br />