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SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued �/� �, <br /> (Complete In Triplicate) -t <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 Joain <br /> County Ordinance No. 1862 Pt e Rules and Regulations of the. San Joaquin Local Health. District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT : <br /> I <br /> Owner's Name Phone <br /> Address121 Zza J,11_e 0j4z,!jA= M 1 <br /> City <br /> Contractor's Name <br /> License <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST; SEPTIC �TANK SEWER LINES PIT PRIVY <br /> SEWAGEPISPOSAL iIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC \ <br /> DOMESTIC <br /> INTENDED USE C WELL <br /> TYPE OF WELL CONSTRUCTION SPECIE CATIONS <br /> Industrial Cable Tool Dia, of Well Excavatio , <br /> Domestic/private Drilled Dia, of Well' Casing + <br /> Domestic/public 1 Driven Gauge of Casing- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection l ]Rotary Type of Grout <br /> Disposal ��" Other _ Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done 4 <br /> PUMP .REPAIR: / / Sate Work Done <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 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 AND A FINAL iINSPECTION. <br /> SIGNED ell TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE),.- <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: j <br /> PHASE II GROUT INSPECTION PHAS III/F AL INSPECTION <br /> INSPECTION BY INSPECTION BY DATE 79 <br /> E H 1426 Rev. - I-74 _ 0/7.7 2M <br />