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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOP .OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton,' Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.1 �.INs--- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> r (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 Distr' .ct. <br /> JOB ADDRESS/LOCATION Q 3 , CENSUS TRACT <br /> s Owner's Name r Phone <br /> Addressp.@� f �` !vc <br /> � .�cl� city <br /> Contractor's Name <br /> A �Gf .License Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESM PIT PRIVY ` ^ <br /> SEWAGE DISPOSAL FIELD 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 is <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven " i Gauge of Casing cofall !' p <br /> Irrigation �. Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other <br /> Other Information <br /> Geophysical ,z Surface Seal Installed By: a <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT / /~ State Work Done <br /> PUMP .REPAIR: State Work Done <br /> ! RES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Des cribe•Material -and_P-r-ocedure—- -- <br /> g 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 /> ,iafter completion-of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of w ll and notify them before putting the .well in use. The above <br /> jinformation is true to he best of'my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING SP CT N. <br /> B SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR.DEPARTMENT USE ONLY <br /> PHASE I <br /> GAPPLICATION ACCEPTED BY DATEr <br /> EADDITIONAL COMMENTS: <br /> SE II GROUT INSPECTION AAll. P 5 FINAL INSPECTIDN <br /> INSPECTION BY DATE V0111 11r? INSPECTION BY DATE 1j,_a0-1 <br /> ., E'H 1.426 Rev. 1-7424 <br />