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,,. / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR. OFFICE—USE IeA 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> I Telephozie: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No -�' P <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. .1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> Contractor's Name C / License !1 <br /> / hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_7AL <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other h / f <br /> r <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYILINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE-OF CONSTRUCTION SPECIFICATIONS } <br /> Industrial i Cable Tool Dia, of Well Excavation <br /> Domestic/private i Drilled Dia, of Well Casing <br /> Domestic/public R Driven Gauge .of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal S <br /> Cathodic Protection 1 Rotary Type of Grout r <br /> Disposal fOther Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type oflPump H.P. <br /> PUMP REPLACEMENT 7 State Work Done I <br /> PUMP :REPAIR: / / State Work Done <br /> c <br />)ES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health bistri6t <br /> ind 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 />'JELL DRILLERS REPORT of the we11 and notify them before putting. the .well in use. The above <br /> Cnformation is true to the best' of. my knowledge and belief. I WILL L FOR A GROUT INSPECTION <br /> RIOR TO G ING AND A NAL I SPE CT ION, <br /> iIGNED TITLE <br /> .(DRAW PLOT PLAN ON REVERSE SIDE) <br />"RASE I <br /> FOR DEPARTMENT USE ONLY <br /> ) <br /> TPLICATION ACCEPTED BY DATE - y <br />,DDITIONAL COMMENTS: 11 <br /> ' PHASE II GROUT INSPECTION PHASE II (FINAL INSPECTION <br /> NSPECT,ION BY k DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1177 214 1 <br />