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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OA;OtFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 made in compliance with San Joaqu: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San oaquin Local Health District, <br /> JOB ADDRESS/LOCAT ON `>D- -�, CENSUS TRACT <br /> Owner's Name y v e� Phone <br /> Address <br /> - City <br /> Contractor's Name License <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /7 RECONDITION�/7 7 <br /> DESTRUCTION / <br /> Lr <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <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 5 <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 /> i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP .REPAIR: � \ <br /> / / State Work Don��� � <br /> u P� nim <br /> iESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> .nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> :IGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I , <br /> ,PPLICATION ACCEPTED Y % DATF�7j/`�� ` <br /> ,DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> .NS PECTION BY DATE INSPECTION BY DATE 7-4 <br /> E H 1426 Rev. 1-74 1-74 2M <br />