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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � o <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. 1862 and thg Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name AN, Phone ._ <br /> Address City ' <br /> Contractor's Name License 41130m— Phone <br /> TYPE OF WORK (Check): NEW WELL - DEEPEN '/ RECONDITION /? DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR/� PUMP. REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD`Q0 ftAlCESSP00L/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 <br /> Do sticJprivate ' Drilled 0-1 . <br /> Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing . . . �` <br /> Irrigation Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ Other Other Information <br /> Geophysical . <br /> - - Surface Seal Installed By: . . . <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. , <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 Distric 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 UTING D 9 $PECTION. <br /> SIGNED TIT3LE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE-ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY DAT --' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III AL INSPECTION <br /> INSPECTION BY _ DAVE INSPECTION BYti <br /> g <br /> F i3 7 4 7 G <br /> n-- 1 z Z I' 7� <br />