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SAN JOAQ1N,-L#kCAL HEALTH DISTRICT <br /> Ft-_ OFFrCE USF: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- �;>, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7-44--X <br /> �/y , <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 Rul p and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION v CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN/% RECONDITION /-7 DESTRUCTION / <br /> PUMP INSTALLATION / / 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 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 Protection Rotary Type of Grout <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: / / State„Work-Done. <br /> �,/� F — <br /> DESTRUCTION OF WELL: Well Diameter r� Approximate Depth��S <br /> Descri Materi 1 andP roceaure wR <br /> P <br /> I hereby agree to comply withal laws an regulations of t Joaquin Loc Health District <br /> and the State of California pert a ning-„to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new we1r1%, -I,w-ill 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) j <br />►PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY / DATE ZZ7/-Z2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO31, PHASE III FINAL INSPECTIO <br /> INSPECTION BY 4 1 J1 DATE INSPECTION BY DATE 7J <br /> E H 1426 Rev. 1-7 4 <br /> �IR 2M <br />