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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FORiOFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�d 7�3}✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .: 6 ' <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 /> s/o Sy I <br /> JOB ADDRESS/LOCATION 3.3f` CENSUS TRACT <br /> Owner's Name Phone <br /> Address L"L )-0 S` City <br /> Contractor's Name License Phone? -- 7 <br /> TYPE OF WORK (Check): NEW WELL/=T DEEPEN '/-7 RECONDITION /=77 DESTRUCTION /-7 <br /> PUMP INSTALLATION f / PUMP REPAIR / / PUMP REPLACEMENT F7 <br /> Other /-7 <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 H.P. <br /> PUMP REPLACEMENT: )$7 State Work Done <br /> PUMP.REPAIR: /? State Work Done <br /> MTRUCTION 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 <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 FOR-A -GROUT INSPECTION <br /> PRIOR TO 4201TING AND A F INS ECTON. <br />{ SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FQR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 17 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III NAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE 6r /— <br /> F' <br /> E H 1426 Rev. .1. 74 1--74 2M . <br />