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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. _aoljo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 17� <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 trade 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 �, '� <br /> Address _ 2-Ap <br /> CityContractor's Naim: <br /> Led License # lS" Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/_`7 RECONDITION / j <br /> 7 DESTRUCTION f <br /> PUMP INSTALLATION PUMP REPAIR/7J PUMP REPLACEMENT /7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INT 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-B 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> • I <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 S <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in.use.. . The above <br /> informatio true to the.. est .of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTI AND A II pE <br /> SIGNED TITLE/ <br /> (DRAW PLOT PLAN ON REVERSE SIDE I <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br />'APPLICATION ACCEPTED BY . <br /> DATE Z� -2S 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR,0UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY /' DATE INSPECTION BY DATE .z <br /> E H 1426 Rev. 1-74 h/75 J <br />