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SAN JOAQUIN LOCAL •HEALTH. DISTRICT <br /> FOF, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) + 466-6781 ' <br />' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date issuedy�V <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 /> k County Ordinance No. 1862 nd he, Ryles d '�egulatia the Sa Joaquin Local Health District. <br /> JOB ADDRESS D <br /> /LOCATIQ CENSUS TRACT <br /> Owner's Name � � Phone �� <br /> Address City <br />` Contractor's Name . iL License )4.13-?3hone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION I / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other / / �. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 <br /> Domestic/private Drilled Dia. of We.11`Casing Q <br /> Domestic/public Driven Gauge of Casing ' <br /> Irrigation. Gravel Pack Depth of Grout Seal i <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 <br /> PUMP..REPAIR.::_ s. S tate,Work..Don <br /> 6r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> F <br /> ! I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> iand the State of California pertaining to or regulating we11 'construction. Within FIFTEEN DAYS <br /> rafter 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 FINAL INSPECTION. <br /> F SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE} <br /> R DEPARTMENT USE ONLY <br /> PHASE I r� <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASEECTION PHASAJWFINAL INSPECTION <br /> INSPECTION B ATE INSPECTION BY DATE - Q- <br /> i Z7 <br /> E _�H 14.26 -. _Rev. 1-74 ` <br />