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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEt7OFFSCE USE. 1601 E. Hazelton Ave. , Stockton,�Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 L,2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - <br /> (Complete In Triplicate) <br /> Application 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 Joaquii <br /> County Ordinance No. 18.62 and, th Rules and Regula of the San -Joaquin Local Health District. <br /> JOB ADDRESSAO/ O � <br /> TION • <br /> CENSUS TRACT <br /> Owner's Name <br /> _ Ph ne <br />{ Address 1� -! <br /> f _ <br /> Contractor's Name <br /> License <br /> hone �� <br /> TYPE OF WORK (Check): NEW WELL. /? DEEPEN/_ RE <br /> _ CONDITION /77 DESTRUCTIONI-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / • IPUMP REPLACEMENT /-T <br /> Other -- <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES 'IT PRIVY <br /> SEWAGEDiSPOSAL FIELD ` ; CESSPOOL/SEEPAGE PIT BOTHER M <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUB <br /> INTENDED USE TYPE OF WELL LIC DOMESTIC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/ rivate Cable Tool Iiia. of Well Excavation <br /> p Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing - .tH <br /> Irrigation Gravel -Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION.- Contractor � <br /> Type of Pump,- . A <br /> H.P. , <br /> PUMP REPLACEMENT / / State Work Done <br /> PUW.REPAIR: Sta <br /> te Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> i � <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-of. my..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 /> PHASE I s .`" FO DEPARTMENT SE ONLY <br /> APPLICATION AC61PTED BY j <br /> ADDITIONAL COMMENTS: DATE , 9, <br /> PRASE II GROUT INSPECTION <br /> INSPECTION BY DATE PHAS II FINAL INSPECTION <br /> INSPECTION BY DATE /--� <br /> .E H 1426 Rev. 1,74 <br />