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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 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 Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0111)4 91-3 <br /> CENSUS TRACT <br /> Owner's Name Phone- <br /> / <br /> Address City . <br /> Contraotor's Name License #AVJ16d Phone A✓ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <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 i1nI <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> /publich Driven Gauge of Casing <br /> Irrigation/. .­ Gravel Pack Depth of Grout Seal { <br /> Cathodic Protection Rotary Type of Grout <br />—Disposal `^ � `' <br /> Other Other Information f <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 11& <br /> . ; Type of Pump . .` :;, H.P. <br /> PUMP REPLACEMENT: ,. - � State Work Done �• Gtica' 0��' <br /> { <br /> PUMP .REPAIR: _-S ta te,,,Work--Done <br />)ESjRUCTION OF WEL—IWe11"Diameter` <br /> `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 /> 4 <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 he best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO ;G UTING IN IN PEC ION. <br /> SIGNED TITLE s <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />?HASE I <br /> APPLICATION ACCEPTED BY DATE �. <br /> MDITIONAL COMMENTS : A <br /> PHASESII !GROUT INSPECTION PHAS l� FINAL INSPECTION <br /> CNSPECTION BY DATE / INSPECTION B z- , : . , � �?ATE — <br /> . -. <br /> E H 1426 Rev. 1-74 �� 1177 . 2M <br />