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!/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =, .FOFF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4.. f hone: <br /> Tele <br /> ;'` P (209) + 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> . 1a <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date -Issued <br /> (Complete In Triplicate) <br />,,: Application is' lereby 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 compli-ance 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 /> s., -.0ianer's Name <br /> Phone <br />` Address <br /> City x,J <br /> ;Contractor's Name License �� <br /> ., Phone . <br /> f <br /> _ a <br /> TYPE OF WORK (Check). -NEW ',WELL /, /,. DEEPEN /7�-RECONDITION=/?DESTRUCTION <br /> - PUMP INSTALLATION" / / PUMP REPAIR PUMP REPLACEMENT <br /> -__�Other- -- <br />, 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ? PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL w PUBLIC DOMESTIC WELL �1 <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial f Cable Tool Dia. of ,Well `Excavation <br /> Domestic/private'. t,Drilled� Dia. of ''Well-Casing l `� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation - --Gravel Pack= ----Depth-of Grout Seal. � <br /> Cathodic Protection Rotary Type of !Grout I <br /> Disposal Other Other information <br /> Geophysical Surface Seal Installed B <br />:PUMP INSTALLATION: # <br /> Contractor <br /> TYPe. of Pump H.P. <br /> PUMP REPLACEMENT: {Xf <br /> State Work Done <br /> i .. <br /> PUMP .REPAIR: — <br /> / / State Work Done <br /> r <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sank 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-noti.fy`them"before'"pu"tting the..well. in use. The above <br /> information is true: to'. the ,best af�my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TOG TI AND F AL' INSPECTION. <br /> SIGNED . <br /> TITLE 04 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> } ` FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY = ` ! �' DATE ' z <br /> ADDITIONAL COMMENTS; p , <br /> PHASE II GRPUT INSPECTION PHASE III NAL INSPECTIONI <br /> INSPECTION BY DATE 'INSPECTION BY DATE „ <br /> E H 1426 Rev. 1-74 1177 ":om <br />