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SAN JOAQUIN LOCAL HEALTH DISTRICT ,�.. <br /> FOS OFFICE USL: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> " Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�Iy dV8'r <br /> E THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Issued <br /> (Complete In Triplicate) ' <br /> Application is hereby wide to the San Joaquin-.LocalHealth District foraermit <br /> p to•CdIIBtrUCt <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <br /> County Ordinance No. 1862 and the_,Rules and Regulations of, the San Joaquin Local Health District. <br /> c.Z _ ` <br /> 3flB'ADDRESS/LOCATION CENSUS TRACT <br /> Owner°s Name� � 0 . A _.. ._.. ...,,� <br /> Phone <br /> Address . ` SO e, <br /> 'City <br /> , 1 <br /> Contractor's Name rJ' <br /> License nes # � phone <br /> i <br /> i <br /> TYPE OF WORK (Check): NEW WELL/_'7" DEEPEN/7 .RECONDITION /7 DESTRUCTION L7 <br /> PUMP INSTALLATION /7 PUMP REPAIR /-7—PUMP. REPLACEMENT <br /> Other / 7 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i} <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 <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/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 ,-1' H.P. <br /> PUMP REPLACEMENT: State Work'Done <br /> PUMP:REPAIR:. L7 'State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> fi <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 the-best ofm knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO ING AND A FINAL I PhT N. <br /> SIGNED ITLE rs✓' . <br /> LOT PLAN ON WffRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 E H 1426 Rev: 1--74 ; 1-74 2M <br />