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SANIJOAQUIN LOCAL HEALTH. DISTRICT <br /> 7F-0r,--OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> AP LICATION 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 ` <br /> CENSUS TRACT <br /> Owner's Name f <br /> Phone. �.. <br /> Address <br /> City <br /> Contractor's Name f jLicense # Phone <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 1CO SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ljQQ' CESSPOOL/SEEPAGE PIT OTHER uJ2il-�0� <br /> PROPERTY LINE » PRIVATE DOMESTIC'WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 1 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of ,Well Excavation rr <br /> Domestic/private Drilled Dia. of Well Casing <br />. �_Domesticf._pub.lic. ----,.— Driven- —_,�_j�Gauge-of-Casing- -� <br /> Irrigation Gravel Pack Depth of Grout Seal o <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. <br /> PUMP REPLACEMENT: /-7 State Work Done r <br /> PUMP .REPAIR: r <br /> / / State Work Donee <br /> AES•TRUCTION OF WELL: Well�Diame.ter—' Approximate Depth � <br /> Describe Material and Procedur """ <br /> I heragree~~to comply with a1 laws an reg. i-ionsth <br /> xo ea. oan quiLocal Health District <br /> and the State of California pertaining to or regulating well 'cco;'tJru`ct-ionWithin 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 of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING A INAL SPECT ION. <br /> SIGNED " TITLE <br /> D W P PLAN ON ERSE SIDE) <br /> �.FO EPARTMENT ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY USE ONLY DATE < <br /> ADDITIONAL COMMENTS: <br /> PHA T INSPECTIO PHA I/ N INSPECTION <br /> INSPECTION BY ATE INSPECTION BY Ar, DATEJ 17- <br /> SW <br /> E H 1426 Rev. 1- /�`r8� 3/76 2M <br />