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Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7 D <br /> THISIPERMIT 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 const uct <br /> and/or install the work hereitildescribed. This application is made in compliance with San Jopquin <br /> County Ordinance No.. 1862 and•the Rules and Regulations of the San Joaquin ocal Health District. <br /> JOB ADDRESS/LOCATION tla CENSUS TRACT�4 # <br /> 4 <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name License Phone <br /> t <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /i� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r�r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> 14 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �• <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ✓' Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump \ <br /> GPUMP REPLACEMENT: / / State Work Done O <br /> PUMP .REPAIR: / / State Work Done <br /> IDES,TRUCTION OF WELL: ' Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II 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 we11 `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 /> jinformation is true to the best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUT IN AND A FINAL INSPE ION. .. <br /> ,SIGNED TITLE _ �. rJ�_ '''j <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t DATE <br /> ADDITIONAL COMMENTS:,'_1 <br /> PHASE I ROUT INSPECTION P / ., N INSPECTIO <br /> 4VINSPECTION BY DATE INSPECTION BY DATE <br /> 1177 2M <br /> U 9A7G n- 1-7A <br />