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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FpF: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7 � r� <br /> Telephone : (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> tApplicaaCVn 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. 1862 and the Rules and Regulations, of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION - '�- "• _ _ CENSUS TRACT <br /> Owner's NamePhone <br /> f Address CityL ` <br /> 4 <br /> Contractor's Name ' w License Phone { <br /> i <br /> �. <br /> .. TYPE OF WORK (Check) ; NEW WELL A:�?,'DEEPEN % ;./ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTAZLATTON '/C PUMP REPAIR / / PUMP REPLACEMENT /? <br /> r Other / / s <br /> ', DISTANCE TO NEAREST: SEPTIC TANK SEWER LIl)TES PIT PRIVY T� <br /> G SEWAGE DISPOSAL FIELD -W— CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f <br /> Industrial 4�C-able Tool xj Dia. of Well Excavation <br /> ✓llomestic/private Drilled` Dia. of Well Casing <br /> Domestic/public Drive_nL-. Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _� fi / - <br /> Disposal Other Other Information f IzS <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . 4� 4C <br /> ,� . Type of Pump <br /> JUMP REPLACEMENT:REPLACEMENT: gip_ / / State Work Done <br /> PUMP ,-REPAIR: / J State Work Done <br /> :DES<TRUCTION OF WELL: Well Diameter Approximate Depth <br /> y 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 /> Iafter 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 bes,4 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO GROU G AND t, FIN NSP ION. 4A. <br /> SIGNED ` TITLE r , <br /> r (D W tLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT.INSPECTION PHASE--III/FINAL INSPECTION <br /> INSPECTION BY DATE - `! 7 _. INSPECTION . s. ) DATEAA- *y <br /> I/7T 2M <br /> E H 1426 Rev. 1-74 ___ <br />