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SAN JOAQUIN LOCAL HEALTH DISTRICT --- <br /> FOt;•'.O.FFICE USE: 1601 E. Hazelton Ave' , Stockton, Calif., <br /> Telephone : (209)' 466-6781 <br /> t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 'T� <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 ADDRESSAOCATION (j /� �` f'. <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone7` <br /> Address d r !;' G'_- 'Lc � j� �. ,� City <br /> Contractor's Namee:�f-� '`' y - � �y ,^ <br /> � r� License ���; G.t Phone <br /> �. <br /> i <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 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 _.• ,,, � - � .�, cly�- <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 Materialnd 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 is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDIA FINAL INSPECTION. <br /> SIGNED ' '� ! , r; :_ rt <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE f--1 "2dP' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DAIS INSPECTION BY C, DATE <br /> E H 1426 Rev.« i-7AL 1177 2M <br />