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SAN J )UIN LOCAL HEALTH DISTRICT <br />)A OiiICE JX' 1601 E. Xielton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S 3/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , S-ZS <br /> (Complete In Triplicate) <br /> lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> /or install the work herein described. This application is made in compliance with San Joaquin , <br /> my Ordinance No. 1862 andel theRulesand Regulations of the San oaquin Local Health District. <br /> ADDRESS/LOCAT ON + CENSUS TRACT <br /> �� )1 1 <br /> er'a Name v Phone.' d�a� <br /> ress ,L City <br /> tractor's Namer/v ' License �� onebd � <br /> �(Z <br /> E OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR _0 PUMP REPLACEMENT /_ <br /> Other / / <br /> TANCE 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 3 <br /> _ Irrigation Gravel Pack Depth of Grout Seal a <br /> _, Cathodic Protection Rotary Type of Grout <br /> _Disposal Other Other Information <br /> —Geophysical Surface Seal Installed By: <br /> O <br /> N <br /> P INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> P REPLACEMENT: / / State Work Done <br /> P .REPAIR: /-7 State Work Donq�� t;Iep <br /> C//ti'j�ll N� <br /> rRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> =reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> =r completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Drmation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> )R TO GROUTING AND A FINAL INSPECTION. <br /> qED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 3E I <br /> .ICATION ACCEPTEDY DAT i <br /> LTIONAL COMMENTS: <br /> PHASE II GXOUTAINSPECTION PHASE I I FINAL INSPECTION <br /> ?ECTION BY DATE INSPECTION BY , DATE r <br /> H 1426 Rev. 1-74 1-74 2M <br />