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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -5-'/S <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 Rules d Regulatio�o7f the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> kc2q <br /> Address <br /> CityC'J <br /> Contractor's Name �. �' License lice Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ EEPEN /% RECONDITION /% DESTRUCTION /_7 �1 <br /> PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT /_7 oQ ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> Q SEWER LIPES Q Q PIT PRIVY c� <br /> SEWAGE DISPOSAL FIELD Q a 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 v <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing ! <br /> Irrigation 'e <br /> g Gravel, Pack Depth of Grout otaSea �q <br /> Cathodic Protection ry Type of Grout �,- <br /> -Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> D <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and 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 a new well, I will furnish the San Joaquin Local Health District- a <br /> WELL DRILLERS REPORT of the well and otify theni'before putting the well in use. The above <br /> inform -on is true to the be .k wledge and belief. I WILT., CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL NS ON. <br /> SIGNED ` TITLE �� -=" <br /> 'I T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _*/::� <br /> WSGROU INSPECTION, dPHASE III/FINAL INSPECTION p <br /> INSPECTION BY DATE SPECTION BY DATE77o <br /> E H 1426 Rrv. 1--74 � ,FT G.e L� -�, S`a r-� ;, 3/76 2M <br />