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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFi?;CE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. . <br /> 'N Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 �-3 Q �'� Q QL S�ENSUS TRACT <br /> Owner's Name 1 Phone <br /> Address <br /> City .1-0 <br /> _72 Contractor's Name License 11 one r-t4y <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %/ RECONDITION /_7 DESTRUCTION /_ (__4 <br /> PUMP INSTALLATION /�MP REPAIR / / PUMP REPLACEMENT /_ <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 a Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/ public Driven Gauge of Casing <br /> L--,Irrigation ��$ravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type, of, Grout <br /> _Disposal - _ Other Other Information , <br /> Geophysical, Surface Seal Installed By: <br /> PUMP INSTALLATION: = Contractor �` p <br /> �. <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 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 INSPECTION, <br /> SIGNED TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY714 DATE 3-- Z <br /> ADDITIONAL COMMENTS: It <br /> PHASE Il GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY e_• V- DATE 7-,,-7y <br /> E H 1426 Rev. I-74 6<2 2M <br />