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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE'OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued "]-15-17 <br /> ' (Complete In Triplicate) <br /> Application is Hereby made to the San Joaquin Local Health District for a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San Joaqutn - <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name A �(% IN 11 Phone <br /> Address 1V 7� l City �j�? <br /> Contractor's NameQ <br /> .License �� �`Y/)/224hone %" <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN/% RECONDITION /_7 DESTRUCTION /_7 j <br /> PUMP INSTALLATION PUMP REPAIR / / FUMP REPLACEMENT /7 <br /> Other <br /> i <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 .j j <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 [f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> 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 Vocal Health District <br /> and the State of California' pertai.ning to or regulating well '-construction. Within FIFTEEN DAYS i <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a k <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 G UTING AND A EjNAL INSPECTION. <br /> SIGNED 1 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)— <br /> tf <br /> �— <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r - DATE ,7 <br /> ADDITIONAL COMMENTS: <br /> PHASE 414ROUT INSPECTION PHOS II INAL INSPECTN <br /> INSPECTION BY Al DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1177 <br />