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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fo_&`OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <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 /> 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 Rule and gulationa the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /! CENSUS TRACT <br /> Owner's Name d4Phone <br /> Address City <br /> Contractor's Name License Phone Q � <br /> i <br /> TYPE OF WORK (Check): NEW [,ALL '/? DEEPEN RECONDITION DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR'/ / 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 WEL L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -. .. ;' <br /> Industrial Cable Tool Dia. of,-Well- Excavation <br /> Domestic/private 4 Drilled Dia..of Well Casing <br /> f Domestic/public # Driven Gaugej of-,Casing _ <br /> I Irrigation " Gravel Pack Depth of Grout Seal �. <br /> Cathodic Protection Rotary Type'-of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Instal d B : R <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: /�/ State Work Done .s.. r. <br /> _ ,0 0• . <br /> PUMP .REPAIR: / / State Work Done !_h <br /> DESTRUCTION 'OF WELL: Well Diameter .�'. Approximate Depth <br /> Describe Material and Procedure <br /> I .hereby agree to comply with all laws and,,re•gulation's,#of the San Joaquin Local Health District <br /> and the State of California pertaining'td-or"regulating well-Zonstruction: Within-FIBTEEN-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 alio�v.e <br /> ` information .is' true to the best of my..knowledge and belief. I WILL C44L FORA GROUT I08PECTION <br /> PRIOR TO q4RUTING AN INAL INSPECTION. <br /> SIGNED TITL G <br /> WffftSE SIDE I !' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT SPECTION PHAS II N INSPECTIO <br /> IN <br /> INSPECTION BY DATE INSPECTION A DATE <br /> 306E H 1426. Rev. 1..74 , 2N <br />