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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /e?,411 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> A (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 .+ <br /> } }` t 1 � a '+ '•, CENSUS TRACT <br /> Owner's Name Phone <br /> Address l City �• '{ {1 �� i <br /> Contractor's Name + I ( ( j }� l r License # Phone ft <br /> t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _j - i SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrialx <br /> Gable Tool Dia, of Well Excavation ' <br /> Domestic/private <br /> Domestic Drilled Dia, of Well Casing <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection �T Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 <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 F1 AL INSPECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE-' - <br /> PHASE I FOR DEPARTMENT USE ONLY. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS-. <br /> P SE 1 GROUT INSPECTI N PHAS /FINAL INSPECTION <br /> INSPECTION BY 1 lel� DATE t ? INSPk;CTION BY DATE <br /> f <br /> E H 1426 Rev. 1-74 1177� 2M <br />