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1(/%1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE E: 1601 E. Hazelton .Ave. ,' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 _/rL <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED `Date Issued <br /> ' 1 (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 Joaquin <br /> County Ordinance No.��ja6Z d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address "/.lQ <br /> City ' S' <br /> Contractor's Name .. ' License # lh�7kl-rhone <br /> TYPE OF WORK (Check): NEW WELL /-7. DEEPEN -/7 RECONDITION /_7 DESTRUCTION' /7 <br /> PUMP INSTALLATION /-7 PUMP- 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 N%O <br /> Industrial Cable Tool Dia. of Well Excavation . <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing . ` <br /> Irrigation Gravel Pack Depth of Grout. Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type 'of Pump <br /> H.P. <br /> 7. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-.REPAIR: a State Work Done �'�/P / ,q,��. '-4!!S_f lwt 0�_ <br /> t a ho/w <br /> ES•TRUCTION 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 le 'aid"` elief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO TING AN A FINAL N. <br /> SIGNS �. r TITLE _ /►, <br /> (DJMWIFM PLAN ON RSE SIDE- <br /> PHASE I <br /> R DEPARTMENT USE ONLY. <br /> • . . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE'II GROUT INSPECTION PHASE III FINAL INSPECTION { <br /> INSPECTION BY DATE INSPECTION BY - DATE 1 <br /> µE H 1426 Rev. 1-74 !n <br /> 1-74 2M <br />