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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORfOFFICE USE: 1/1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �V-s`,57P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 J3-7,!� <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 J aq'uin Local Health District. <br /> .2 <br /> JOB ADDRESS/LOCATION �� 4 <br /> iU CT <br /> JIV L <br /> Owner's Name 44 6r Phone <br /> Address <br /> City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN 17 RECONDITION /-7 DESTRUCTION %f <br /> PUMP INSTALLATION j0 PUMP REPAIR <br /> Other PUMP REPLACEMENT 17 <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 <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 fH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done _ <br /> ES;TRUCTION OF WELL: Well Diameter Approxi to Depth <br /> De ekr <br /> ribe Mati 1 and Procedure <br /> 0 4d <br /> I hereby agree to comply ith all laws and regulations of-the an Joaquin L al He th District <br /> and the State' of California pertaining td or "regulat.ing 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 of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRWTING AND A FINAL 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 IIYLINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i E H 1426 Rev. 1-74 <br />