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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. � I <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 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 A/ CENSUS TRACT l! <br /> Owner's Name Phone? !1 7^ �/ <br /> Address �p City j , <br /> Contractor's Name C -_ LicensePhone - �� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION / / 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 <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 fn <br /> Domestic/private Drilled Dia. of Well Casing <br /> _"_Dbmestic/public —" '-Driven Gauge of Casing � <br /> 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. 7 <br /> PUMP REPLACEMENT /7 State Work Done <br /> _ t ` <br /> PUMP .REPAIR: /— State Work Done iIi I <br /> DESTy RUCTION 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 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 to best of m owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRD I AND th NAL INSP ION. <br /> SIGNED TITLE <br /> W PUID-T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE „S`: I P <br /> E H 1426 Rev. I-74 <br /> 3/76 2M <br />