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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOO OFFICE USE: 1601 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 �S <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 J 7 Ll �`„ ' %� �' :,. CENSUS TRACT <br /> .I <br /> Owner's Name / -', , '” Phoned <br /> Address �� ` -' }� City <br /> Contractor's Name License , Phone <br /> TYPE OF WORK (Check): NEW WELLDEEPEN/-7 RECONDITION /-7 DESTRUCTION %j <br /> PUMP INSTAL TION /—/ PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK sO f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL lbolb <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 1 <br /> Irrigation Gravel Pack Depth of Grout Seal 15-6 <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 Work Done elk <br /> PUMP :REPAIR: /7 State Work Done <br /> Z S•TRUCTION 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 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLE S REPORT of the well and notify them before putting the..well in use.. The above <br /> information is rue toe-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR U N ANDA INAI,INSPECTION. , <br /> SIGN TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATED/1. S <br /> ADDITIONAL COMMENTS: <br /> P i5M INSPE ION PHM II PINAL INSPECTION <br /> INSPECTION BY TE INSPECTION BY ATE 75 <br /> C61 <br /> ;E H 1426 Rev. 1-74 1-74 2 <br />