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Y _ SAN JOAQUIN LOCAL HEALTH DISTRICT r� <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. { <br /> Telephone: (209) 466-6781 /� / <br /> APPLICATION FOR WELL CONSTRUCTION OR 'UMP PERMIT Permit No. `! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � 7 <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 N Ca :�J 1/' -' CENSUS TRACT _ <br /> Owner's Name -get Phone <br /> Address <br /> City ZO-4 r <br /> Contractor's Name License Phone,3 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/_/ RECONDITION DESTRUCTION /-7PUMP 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 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL (1� <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 /> 5 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> { Type of Pump ; H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION 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 i true to the best of my k owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR NC.4AND A F INSPEgMN. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) jr <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� DATE / Z _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> `"0/77 _ 2M <br />