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i <br /> FO�_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F OFFICE 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 <br /> PP y q 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 anegulations of the S oaquin Local Health District. <br /> JOB ADDRESS/LOCATION � l � CENSUS TRACT a <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License Phone <br /> TYPE OF.WORK..(Check) : NEW WELL / / DEEPEN, /7// RECONDITION / / DESTRUCTION <br /> PUMP .INSTAZtATION / / 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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private - Drilled Dia. of Well Casing <br /> Domestic/public f 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 /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / % State Work Don, <br /> _ / <br /> PUMP .REPAIR: / / 'State Work Done i <br /> bESjRUCTION OF WELL: Well'Diametet 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 t he best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING M2 FIN4L INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7� i <br /> i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPPICTTON PHASE,_tIII/F1,NAL INSPECTION <br /> "NSPECTION BY DATE INSPECTION BY DATE - za 7� <br />