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1 � 9 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6787 <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'L the San Joaquin Local Health District for a permit to const[uct <br /> and/or install the work herein described. This application is made in compliance with San Jo4.quin <br /> County Ordinance No.: .1862 and the Rules and Regulations of the San Joaquuiiin� ocal Health District. <br /> JOB ADDRESS/LOCATION CJ Si+ CENSUS TRACT�� <br /> Owner's Name Phone <br /> Address City ,� � i <br /> r23" License Phone / <br /> Contractor's Name rlti <br /> X <br /> f __ _ <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN '/ / RECONDITION / / DESTRUCTION /-J ` <br /> PUMP INSTALLATION J J PUMP REPAIR / J PUMP REPLACEMENT <br /> E Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �rr <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER `U <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> i/' Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> ' Irrigation .1 Gravel Pack Depth of Grout Seal <br /> k Cathodic Protection 1 Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical. Surface. Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type af Pump 7 H.P. \ <br /> PUMP REPLACEMENT: / / State Work Done O <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 /> land the State of California pertaining to or regulating wel1 "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 GROUTIN AND A FINAL INSPE ION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> .APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: , l <br /> PHASE I ROUT {INSPECTION P / N INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t <br /> UP/] 2M <br /> r <br /> B u I AI)9 nom.. 1_7A <br />