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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOIA(;OFFICE USE: 'j 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l 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 �compl.iance with San Joaquin! <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> . 17 7r -7 IVw dk `­ecr <br /> 3OB-,ADDRESS/LOCATION e' <br /> • D CENSUS TRACT <br /> 0 er's'YName 71-AOZ7 — - Phone r. 4 <br /> Cit /—,a / <br /> Address ✓ D Y <br /> Contractor's Name License ## Pte? Phone, �/� <br /> TYPE OF WORK (Check): NEW WELL -// T, EEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> 'PUMP INSTALLATION /7,7�PUMP REPAIR / / PUMP REPLACEMENT /7 <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 moble Tool Dia. of Well Excavation ag <br /> L_— Domestic/private'' Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout A! Ir <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:: <br /> PUMP INSTALLATION: Contractor <br /> € Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: ./7 State Work Done <br /> f ESiRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t r <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 GROVINg AND A FIN INSPECTION. <br /> .SIGNED * TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> T' - -- -- FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ; .'.APPLICATION ACCEPTED BY DATE _ <br /> t ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYQ DATE INSPECTION BY DATE a2 ' <br /> `-� --- <br /> } _ E H 1426 Rev. 1-74 1-74 2M -- <br />