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SAN JOAQUIN LOCAL. HEALTH DISTRICT ._ ✓�, <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued P- 3-7 <br /> ` (Complete In Triplicate) <br /> Application is Aereby 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 CENSUS TRACT " <br /> Owner's Name Phone �f <br /> Address .�{ City <br /> Contractor'sName ,y�C�License �� CQo Phone <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 1-4aEWER �-INES - gIT PRIVY <br /> SEWAGE DISPOSAL FIELD;- CESSPOOL/SEEPAGE PIT _ S 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 It t <br /> mestic/private Drilled Dia. of Well Casing CQ t _ A <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout S al <br /> Cathodic Protection Mary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done i <br /> DESTRUCTION OF WELL: W is eter 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 •'constructfon. Within FIFTEEN DAYS i <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 /> inform�ionis true to th myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR UTING AND NAL I S ON <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) �— <br /> /FOR,DEPART,.MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 <br /> ADDITIONAL COMMENTS: 7Z <br /> PHASE Tj GROU INSPECTION PHASE I I/FINA1 INSPECTION j <br /> INSPECTION BY DATE jj-�,�«7 ' INSPECTION BY DATE <br /> �! �� , Cla z yr /� <br /> E H 1426 Rev. 1-74 / 7.7 t <br />