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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. <br /> e THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete In Triplicate) <br /> Applicationhereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or insta l the work herein described. This application is made in compliance with San Joaquin., <br /> County Ordinance No. 1862 an he Rul7aj and Regulations of San Joaquin Local Health District. <br /> JOB ADORES O T CENSUS TRACT <br /> Owner's Na Phoneme_ <br /> Address City <br /> Contractor's Name ����^ License��7OU <br /> Phone� f �rr <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 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 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 1 <br /> Cathodic Protection Rotary Type of Grout - <br /> Disposal Other --Other Information - I ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor `Q <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done k <br /> t' <br /> PUMP �.REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dept <br /> Describe Material and Procedure <br /> I hereby agree to comply with all .laws and regulations of the San Joaquin Local Health District A <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 /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> 1777 2M <br />