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A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POE -OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is�by made to the` San Joaquin Local Health District for a per <br /> 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 /> 4kd CENSUS TRACT-' <br /> JOB ADDRESS/LOCATION I -- - <br /> Phone <br /> Owner's Name / <br /> Address S.' City S/L«. <br /> Contractor's Name 4 License �� `y3 PhoneL 7-( <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /T/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR jPUMP REPLACEMENT I <br /> other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIEZD 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 �t3 <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. <br /> PUMP. REPLACEMENT: / / State-W©.rk.'Done <br /> 6 <br /> PUMP REPAIR: Lk State Work Done <br /> DES-TRUCTION OF <br /> 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 'construcrion. 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 thewell in use. The above <br /> information is true to the best of. my k2r le e elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UT NG AND A FINAL INSPE ON. <br /> SIGNED TLE <br /> 71 ( RAW LOT PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE, I <br /> APPLICATION ACCEPTED BY DATE 3 � _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION — <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> k. E H 1426 Rev. � 1-74 _-- — — <br />