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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: l 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , <br /> � n THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -TSr <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 Regulations of the. San. Joaquin Local Health District. <br /> � <br /> JOB ADDRESS/LOCATION � �' � CENSUS TRACT <br /> Owner's Name '—T -x , <br /> - - �t_� < r Phone <br /> Address <br /> c/'G�diir <br /> City <br /> Contractor's Name <br /> License # old Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /-7 DESTRUCTION f-7 <br /> PUMP INSTALLATION je;U PUMP REPAIR 1-7 PUMP REPLACEMENT 17 <br /> Other 1-7 <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 Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing � Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump c� gip <br /> PUMP` REPLACEMENT: Ll State Work Done <br /> PUMP:REPAIR: /-7 State Work Done <br /> PES-TRUCTION 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 the well and notify them before putting the. well i"se.. The above <br /> information is true to the best of my knowledge and belief. I WILL CAL!FO INSP TION <br /> PRIOR TO GROUTING AND NAL INSP ION. <br /> SIGNED TITL �2- <br /> W PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I ,('�/ '] <br /> APPLICATION ACCEPTED BY DATE/ b / <br /> ADDITIONAL COMMENTS: <br /> PHASE Ij 9ROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY =:r DATE _ �I,S INSPECTION BY '/2 7 DATE <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />