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n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf* OFFICE USE: 1 <br /> 601 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 <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> j <br /> Address i, City <br /> Contractor's Name eCorl4ellvi License #,;Z&?44e Phone � �� <br /> X <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN '/% RECONDITION /_7 DESTRUCTION /_7 � <br /> PUMP INSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT /-J In <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Zg�� SEWER LINES _Z 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing yr &,D <br /> Irrigation Gravel Pack Depth of Grout Seal f '� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Ge6physical Surface Seal Installed By: rre.cy <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 wel.l "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 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 GROUTING-D- A F AL S I <br /> SIGNED TITLE f <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1 -2-2-- 2Z <br /> ADDITIONAL COMMENTS: ZY <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE. 2 <br /> E H 1426 Rev. 1-74 <br /> 1177 2M <br />