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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EO . OFFI E USE; 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J <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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Y Name Phone <br /> Address <br /> City 01,4 <br /> Contractor's Name 11VLicense Y_�??%/� Phone � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/�/PRECONDITION /—// DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT OTHER -- a <br /> PROPERTY LINE/19APRIVATE DOMESTIC WELD 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 -2 <br /> Irrigation Gravel Pack Depth of Grout Seal UJ p <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 1 <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-.- /T/- State-Work Done- <br /> PES4RUCTION OF WELL: Well Diameter Approximate Depthaa' � ' <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 t the be � of y kn 1�geandelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T AN A FINAL INS TIO <br /> SIGNED TITLE <br /> ELI-- <br /> (DW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY __ �� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASELIAIGROUTINSPECTION PRASE /FINAL INSPECTION <br /> INSPECTION BY ATE /_/ " �� INSPECTION BY DATE 2— • 7 <br /> 1 X77 <br /> E H 1426! Ra.:_ I_7[ _ 2P4 <br />