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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />F0F OFFICE USE: 1631 E. Hazelton Ave . , Stockton, Calif. <br />Telephone : (209) 466-6781.- <br />r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7] <br />THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED- Date Issued <br />Complete In Triplicate) <br />Application is hereby made to the San Joaquin Local Health District fora permit to construct <br />and/or install the work herein described. This application is made in compliance with San Joaquin <br />County Ordinance No,s•, 1862 and the Rules and Regulations of the Sa oaquin Local Health District. <br />JOB ADDRESS/LOCATIO CENSUS TRACT <br />Owner's Name Phone <br />x <br />Address0 J4 city <br />f Contractor's Name icense #Afola,&Phone , - <br />TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br />PUMP INSTALLATION / / PUMP REPAIR / / PUMP. REPLACEMENT <br />Other l/ / <br />DISTANCE TO NEAREST: SEPTIC DANK SEWER LINES PIT PRIVY <br />II`SEWAGE DISPOSAL FIELD CESSPOOL/SEEP- GE PIT OTHER <br />p <br />PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />Industrial Cable Tool Dia. of_We11-.Excavation <br />Domestic/private Drilled Dia. of Well -Casing <br />Domestic/public Driven Gauge of Casing,, <br />Irrigationanon I Gravel Packck Depth.-of-Grout Seal <br />Cathodic Prote on I Rotary Type of Grout <br />Disposal I Other Other Information v <br />Geophysical 1 Surface Seal Installe <br />BY: <br />PUMP INSTALLATION: Contractor 42 <br />Type of Pump H. <br />PUMP REPLACEMENT; <br />Lyl <br />State Work Done <br />PUMP .REPAIR: State Work Done <br />DES-TRUCTION OF WELL: Well Diameter .Csf, Approximate Depth <br />Describe Material Procedure <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 anew 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 G TING _ DAF NAI;. INSPECTION. <br />SIGNED TITLE <br />y <br />DRAW.-PLOT PLAN ON REVERSE' SIDE) <br />FOR DEPARTMENT USE .ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY liti/ DATE <br />ADDITIONAL COMMENTS: i <br />PHASE II GROUT INSPECTION PHASE' II ANAL INSPECTION- <br />INSPECTION NSPECTIONINSPECTIONBYDATEINSPECTIONBYDATE <br />F 14 ALTA no.. 1_7.. <br />Y o.71 _ 2M