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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: /r'� 160 . E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> w <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ? �� <br /> CENSUS TRACT 2-Y?-030'02' <br /> Owner's Name/ Phone <br /> Address <br /> City <br /> Contractor's Name � j` Z ,� - License #1? Phone <br /> ji <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/% DEEPEN RECONDITION /% DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION _ <br /> PUMP REPAIR / / PUMP REPLACEMENT /-J <br /> Other /% — CIA <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL.` � <br /> k <br /> INT DED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ! ; <br /> ;Industrial l - �+ ;' <br /> Cable'Tool ��¢ Dia':--of -Well 'Excavation-;­ <br /> Domestic/private <br /> Excavation-„• . . . .- ~- '� <br /> Domestic rivate � <br /> /P Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing �� <br /> Irri ation ' i <br /> g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary: -t `_-Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical <br /> _ Surface Seal Installed BY: � <br /> ell, , r <br /> PUMP'�INSTALLATION: Contractor <br /> Type yf o f Pum <br /> p H.P. d� <br /> PUMP REPLACEMENT: - / 9/ State Work Done <br /> ' i <br /> PUMP .REPAIR; ` J� S <br /> _ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter -� <br /> � 4 <br /> Describe Material andiProced.ure <br /> I hereby agree t-a`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 furnish the a new well, I will furnithe San Joaquin Local Health District a <br /> EP <br /> WELL DRILLERS REPORT of the well and notify them before putting the well. in use. The above <br /> information is true. to the bestVof my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO G UTING AND;A, FINAL INSPECTION. <br /> SIGNED TITLE �A'A <br /> ` (DRAW PLOT PLAN ON REVERSE SID8) f + E. <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I --- <br /> 4PPLICATION ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS: !M <br /> PHASE II GROUT INSPECTION F I /FINAL INSPECT/ N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> J�,, <br /> }� 7, 2M <br /> <=E-H3426 Rev. 1-74-- 7 <br />