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SAN JOAQUIN LOCAL HEALTH DISTRICT �/' <br /> FOfi.OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. .r <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 mhde -in compliance with San Joaquin <br /> County. Ordinance No. 1862 and the Rules and Regulations of the' San Joaquin Local Health District. <br /> JOB ADDRESSfb0@*ft0N <br /> 1-4 CENSUS TRACT <br /> Owner's NameWz /l Phone <br /> Address <br /> city " <br /> Contractor's Name dij tj License j#x Phone /- <br /> i <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN '/? RECONDITION /? DESTRUCTION /_ <br /> PUMP INSTALLATION /F PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> ,k <br /> DISTANCE TO NEAREST: SEPTIC TANK � Q SEMEg yINES IT PRIVY �! <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT �+-OTHER <br /> PROPERTY LINE- PRIVATE DOMESTIC WELLS—Le-PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL_ CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation "7 <br /> Domestic/private - Drilled Dia. of Well Casing ' s <br /> Domestic/public Driven Gauge of Casing 12- s <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information,'-" <br /> Geophysical �. — � Surf ace Seal installed B <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> I '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 /> 4nd 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 andnotify 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 />?-RIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED LE �• <br /> ( PLO L ON REVERSE SIDE <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY - <br /> ADDITIONAL COMMENTS: DATE -1r, �-- <br /> GROFlT INSPECTION P SEI : FINAL INSPECTION <br /> INSPECTION 'BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-.74 ,-a _-- <br />