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7 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone : (209) 466-6781 7Sr' du14` <br /> APPLICATION FOR WELL CONSTRUCTION OR FUI`IP 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 /> _tnd/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 /> OB ADDRESS/LOCATION f e%7 Cf ,9/ Y i; CENSUS TRACT <br /> Owner's Name +- � Phone <br /> riddress <br /> City <br /> ontractor's Name ''f,✓I' ` r� ;�•- _ �` License # Phone ` <br /> r " <br /> '"YPE OF WORK (Check) : NEW WELL /<-('"DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PIUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / / <br /> ISTANCE 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 l --/table 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 /> ✓,' , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ► , . -+.t . H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> UMP .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 /> red the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> _fter 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 /> 'reformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ZIOR TO GROUTING AND A FINAL INSPEQTION. <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> rn3ASE I <br /> APPLICATION ACCEPTED BYE , DATE <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ,yc. DATE Z - INSPECTION BY DATE <br /> - E H 1426 Rev. 1-74 1-7L ?M <br />