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I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. _71#-7e PSI-aye <br /> Telephone : (209) 466-6781 r� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / 4 <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 Joaquin <br /> County Ordinance No. AA62a d t Rules and Regulations of the San Joaquin Local Health District. <br /> yy �� <br /> ,TOB ADDRESS/LOCATI( CENSUS TRACT <br /> Owner's Name Phone ue, 3-4/3-7 <br /> Address City <br /> Contractor's Named License <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION N-f PUMP REPAIR / / PUMP REPLACEMENT /—T w <br /> Other / J S <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PTT _ OTHER <br /> PROPERTY LINE/94 RIVATE '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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 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 /> 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 /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY X DATE - Z'7 <br /> ADDITIONAL COMMENTS: <br /> PHASE IT'GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY ?2- <br /> DATE - Z- INSPECTION BY DATE <br /> �^ <br /> E H 1426 Rev. , 1-74 <br /> f <br />