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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOHrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '3 74) <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ,i (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 :Wade in compliance with San Joaquin <br /> ,County-'Ordinance No. 862 and 'the Rules and Regulations of the SaJoaquin Local Health District, <br /> kJrZ(Z A),1.14 o ��..,,(( <br /> }� ,� ' l" SUS'TRACT ala-p34-2� <br /> �JOB ADDRESS/LOCATION �' /k�-C Y�� �Y (n <br /> Ov aer's Name Phone <br /> f <br /> r <br /> Address city _ <br /> License 4/� 23 Phone�.� - <br /> Contractor's Name i <br /> TYPE OF WORK' (Check): NEW WELL /-7 DEEPEN /� RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTAL ��PAJ� PUMP REPLACEMENT IT <br /> Other <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 <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 4Type of Grout <br /> Disposal . - Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> k PUMP INSTALLATION: :' Contractor <br /> Type; of-Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> 4 State Work.Doner <br /> PUMP '.REPAIR: r <br /> IV <br /> ES;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 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 GROU11M AXV A FWL . PECTION. ` <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> _ ADDITIONAL COMMENTS: ° <br /> OUT SPECTION PHASE III FINAL INSPECTION <br /> PHASE II GR <br /> INSPECTION BY DATE INSPECTION- BY DATE r <br /> E II 1426 Rev. 1-74 <br /> 1-7 <br />