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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB• &F-FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is hereby made to� the San Joaquin Local Health District fox 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 ands the Rules and Regulations of the San Joaquin Local Health District. <br /> jy(f <br /> JOB ADDRESS/LOCATION �'�JL� f CENSUS TRACT .• - I <br /> Phone <br /> Owner's Name <br /> Address /" City <br /> Contractor's Name <br /> License Q � Phone <br /> I� i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION -/—/ DESTRUCTION 1-7 <br /> PUMP-!INSTALL N"/ / REPAIR / / PUMP EPLACEME T <br /> Other- <br /> 4 <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 i Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> -" <br /> Domestic/public it Driven"'"` Gauge g of Casing <br /> F Irrigation a Gravel Pack Depth of Grout Seal En <br /> Cathodic Protection ! Rotary Type of Grout <br /> Disposal 1 Other Other Information ' <br /> - - -Geophysical ` -- Surface-Seal Lnstalled .B Y r <br /> PUMP­INSTALLATION: Contractor <br /> I <br /> H.P. <br /> Type of Pump <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 thelwell and notify them before putting the .well ' use. The above <br /> information is true t t I2best of my knowledge and belief. I WILL CAIS OR A GROUT INSPECTION <br /> PRIOR TO G TING AND FI ,AZ I SPE I <br /> TITLE <br /> SIGNED <br /> ;IKDRXW POT FLAN ON RE RSE SID <br /> DEP TMENT USE ONLY <br /> PHASE I DATE /C! <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS II/F AL INSPECTION <br /> k PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY J DATE <br /> 3/76 2M <br /> E H`11426 Rev. 1-74 . <br />