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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7WE! <br /> 1601 E. Hazelton Ave. , Stockton, Calif. 4/7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�f- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate 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 <br /> Owner's Name Phone R-CrA <br /> 11 <br /> Address City uAL <br /> Contractor's NameLicense <br /> -�Ihne Phone <br /> L <br /> a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> ALL _ <br /> PUMP INSTATION � PUI-'REPAIR $/ / PUMP REPLACEMENT <br /> Other <br /> tl <br /> DISTANCE TO NEAREST: SEPTIC TANK 10,1- SEWER LINES U 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 Diarnf Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation / Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type ofGrout <br /> Disposal Other Other Information - <br /> Geophysical Surface� Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpi7NX H.P. _:;o <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 GRO ING AD A I ION. I <br /> SIGNED TITLE k <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE ,r <br /> ADDITIONAL COMMENTS* <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY P DATE f INSPECTION BY DATE <br /> E H 1426 Rev. • 1--74 � � 6, 77 - 2M <br />