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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton ,Ave.v, .Stockton, Calif. <br /> I Telephone: (209) 466-6781= I,r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicdtion 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 /> F F <br /> JOB ADDRESS/LOCATION.. t CENSUS TRACT <br /> Owner's Name J�Ij. Phone <br /> AddressIF <br /> 7 11 City i <br />�a Contractor's Name t. License # Phone <br />� 1 <br /> TYPE OF. WORK (Check): NEW WELL/? DEEPEN '/_7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other /_7 � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> j 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 rn <br /> Domestic/private• ' ' Drilled . -mow Dia. of Well Casing <br /> R <br /> ­. <br /> Domestic/publics Driven Gauge of Casing <br /> J "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 H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP -.REPAIR; / State Work Done <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't of California pertaining to or regulafiing' we11 construction. Within FIFTEEN DAYS <br /> after completion of my work on 'a new well, I ;gill furbish the San Joaquin Local Health District a <br /> WELL DRILLERSRT of t e well and notify them befo utting..the..well in use.. °The above <br /> i information is tr a to •th - es of my.knowledge belief. I WILL CALL FOR A GROUT, INSPECTION <br /> PRIOR TO 'GROUT AND. A FI SPECTION. <br /> SIGNED TITLE , <br /> DRAW PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1, <br /> APPLICATION' ACCEPTED .BY _ DATE (}' <br /> ADDITIONAL COMMENTS: 'I .. <br /> PHASE II 4EQUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 4 E H 1426 Rev. 1-74 <br />