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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 <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 CENSUS TRACT 211 <br /> Owner's Name ` Q�, y �� Phone <br /> Address ,v. City It <br /> Contractor's Name License # ?qojV/, Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / 7 PUMP REPAIR /-J PUMP REPLACEMENT 17 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK A2nL SEWER LINES PIT PRIVY <br /> �[ SEWAGE DISPOSAL FIELD /00 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 Xr - �1 <br /> Domestic/public Driven Gauge of Casing //1) j,y °ice <br /> Irrigation Gravel Pack Depth of Grout Seal 1.0 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP .REPAIR: /_7 State Work Done <br /> PES-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 DRILLERS REPORT of the well and notify them before putting thewell 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 GIROUTING ANDA INAL IN ECT 0 . <br /> SIGNED ITLE <br /> DRAW T PkN ON REV E SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1�-� DATE )-'-7-V <br /> ADDITIONAL COMMENTS: <br /> PHASE II G T INSPECTION ky <br /> PHAS I I AL INSPECTIO <br /> INSPECTION ATE INSPECTION BY TE <br /> E H 1426 Rev. 1-74 1-74 2M <br />