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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—B"r'OFFICE USE: Z1601 E. Hazelton Ave. ,:' <br /> ve. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�.5-/l . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE;ISSUED,; .�. ,h i.Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made''tn the 'San Joaquin Local 'Health..District-.for a permit to.iconstruct <br /> and/or install the work herein described. This application is made;in ,ccmpliance with.,:SAn.,Joaquin <br /> � <br />{ <br /> County Ordinance No, 1861 and the Rules and Regulations of the San joaqufn.Locak. Health: Di�trict. . i <br /> JOB ADDRESS/LOCATION f1 _ ,,, CENSUS;_,TRACTIF <br /> Owner's Name <., .• , j� . , <br /> Phone <br /> Address i City , .. <br /> .Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELLDEEPEN '/7 RECONDITION -7 DESTRUCTION <br /> PUMP INSTIL:TION / PUMP REPAIR 7 PUMP REPLACEMENT ` <br /> -Other - <br /> :DISTANCE <br /> Other:DISTANCE TO NEAREST: SEPTIC TANKQ 1 SEWER LINE - PIT PRIVY ~ ' <br /> SEWAGE DISPOS FIELD CE SPOOL/SEEPAGE PIT ' OTHER1 <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS c � + <br /> Industrial Cable Tool. Iiia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dowestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of, Grout Seal I <br /> Cathodic Protection Rotary Type of Grout - <br /> Disposal -- OtherOther Information; <br /> Geophysical. Surface Seal, Installed 1y: -_ <br /> PUMP INSTALLATION: Contractor <br /> i Type .of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done a <br /> PUMP :REPAIR: /'% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. J� - c µ E Approkimate Depth <br /> Describe Materi 1 nd Procedure <br /> I hereby agree to comply:.with all lams and regulations of the San Joaquin Local Health District, 1 <br /> and the State of California pertaining to or regulating well''constructida. Within FIFTEEN DAYS I <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-be' st.of .my knowledge and belief. . .1 WILL ,CALL FOR..A:GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED =:: TITLE. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> _ <br /> F-W DEPARTMENT USE ONLY <br /> PHASE I 1?w <br /> aAPPiICATION ACCEPTED BY DATE <br />'i ADDITIONAL -COMMENTS: 46 <br /> PHASE II GROUT INSPECTION PHASE II lm TNsPEcTwN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E-H 1426 Rev: 1-74 4/75 2M- <br />