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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�.iOFFICE USE: 1601 E. Hazelton Ave - , Stockton, Ca '7`d C. <br /> Telephone: (209) 466-67 0 <br /> APPLICATION FOR WELL CONSTRUCTIOW PERMIT. ermit No. 7 <br /> ,d� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE I � to Issued a� <br /> rt " (Complete In Triplicat C� <br /> Application is hereby made to the San Joaquin Local He Di t4an <br /> � a permit to construct <br /> and/or install the work herein described. This applica ' n compliance with San Joaquin <br /> County Ordinance No. '1862 and the Rules and Regulations hie' Joaquin Local Health District: " <br /> JOB ADDRESS/LOCATION -CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name . 40N4 � <br /> ---,...._. License #-97%1D Phone Q?07 <br /> TYPE OF WORK (Check) -. NEW WELL /=77 DEEPEN L/-7 RECONDITION /_7 ^^DESTRUCTION /_7 <br /> PUMP INSTALLATION /X/ PUMP REPAIR /_7 PUMP REPLACEMENT f7Other -- <br /> DISTANCE TO NEAREST: T 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 Took 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 H.P. <br /> t <br /> PUMP REPLACEMENT: . L/ State Work Done <br /> PUMP-:REPAIR: �- <br /> • � "/?—State Worst Done' - - - <br /> ES TRUCTION OF WELL„ Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> T 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 complet'3on-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 GROUT INSPECTION <br /> PRIOR TO 2E2MNG AND A FIN INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/ INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />