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FOP--'.'OFFICE JOAQUIN LOCAL HEALTH DISTRICT <br /> .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 1 YEAR FROM DATE ISSUED <br /> Date Issued�� . <br /> (Complete In Triplicate) <br /> Application is dere ma a 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. 18C622aan�dj t <br /> �e Rules and Regulations of the San Joaquin Local Heal thJOB ADDRESS/LOCATION / / <br /> CENSUS T <br /> �J RACT <br /> Owner's Name <br /> Phone d � <br /> Address <br /> City <br /> Contractor's Name r 1� ef����Ph L r������ <br /> Licens one <br /> TYPE OF WORK (Check) : NEW WELL i <br /> / / DEEPEN/_/ RECONDITI N ? DESTRUCTION /� . <br /> PUMP INSTALLATION / / PUMP REPAIR � PNME REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESw, <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELI, PUBLIC DOMESTIC WELL- <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Irrigation lic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br />-Disposal yp <br /> Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: T / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply w 11 ith all laws and regulations of the San Joaquin Local Health istriet <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 /> Enformation is true to the best of my knowledge and belief. <br />'RIOR TO I WILL CALL FOR A GROUT INSPECTION <br /> GROUTING AND A FINAL INSPECTION. <br /> iIGNED <br /> (DRAWPLOT FLAN ON REVERSE SID <br />'HASE I <br /> FOR DEPARTMENT USE ONLY <br />►PPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II G P ION PHAS III/FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION DATE <br /> 1 13 <br /> ' I <br /> E H 1426 Rev. 1-74 1IT7 <br /> �,�.. <br />