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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 . <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 acid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT7YCENSUS TRACT <br /> Owner's Name Phone <br /> Address11 3 10 - J <br /> City <br /> Contractor's Name ` License # Phone <br /> TYPE OF WORK (Check): ' NEW WELL17 DEEPEN/-7 RECONDITION FT DESTRUCTION r7 <br /> PUMP I TALLATION /-7—PUMP REPAIR 1-7-pump REPLACEMENT /7 <br /> Ik Other` <br /> DISTANCE TO NEAREST:SEPTIC*-TANK -.SEWER LINES--SPIT-PRIVY <br /> SEWAGE�.DISPOSAL .FIELD� CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY'LTNE =-'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 EE Drilled Dia. of Well Casing Q <br /> Domestic/public li Driven Gauge of'Casing <br /> Irrigation tf Gravel: Pack "Depth of�Grout, Seal <br /> Cathodic Protection j Rotary !rType .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 Dane - f <br /> PUMP :REPAIR: �.. t <br /> . - L7 State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter ` f`, a <br /> Describe Material and Procedure Approximate Depth <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 we11 construction. Within FIFTEEN DAYS <br /> after completion of my work '.'on a new well, 'I`Grill furnish the .San Joaquin Local Health District=a - <br /> WELL DRILLERS REPORT of the well and notify them befoie putting- .the well in-use. The above <br /> information s true t th best my.knowledge and belief. I WILL CALL FOR -AGROUT INSPECTION <br /> PRIOR. TOG N A NAL IN ECTION. <br /> —SI GNEDTITLE <br /> v. (DRAW PLOT .PLAN_._ON_REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II. GROUT INSPECTION PHASE IUIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1r E H 1426 Rev. 1-74 <br /> '� ' 1-74 2M <br />