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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i1 Telephone:'} (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. — <br /> THI:S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i Date Issued // 7 <br /> .(Complete In Triplicate) <br /> Application is hereby made to�lthe 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 and egulations :of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION z><O(` <br /> �5- <br /> C� 4 <br /> Owner's Name Phone - <br /> Address . <br /> ' City <br /> C <br /> Contractor s Name License Phone <br /> +I t <br /> TYPE OF WORK (Cheek) : NEW WELL I / DEEPEN / / RECONDITION / / DESTRUCTION /rT <br /> PUMP INSTALLATION / I PUMP REPAIR I / PUMP REPLACEMENT <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 p . <br /> Industrial it Cable Tool Dia, of Well Excavation N <br /> Domestic/private j'1 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 r <br /> Disposal !1 Other :+ Other Informatioxi <br /> Geophysical Surface Seal Insta led B <br /> t , Q <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1 <br /> PUMP REPLACEMENT: / / State Woxk:_b9.je <br /> k F . <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well'rpiameter . <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> regulating we11 'construction. Within FIFTEEN DAYS <br /> and the State of California pertaining to or 8 8 <br /> +1 after completion of my work-'on a new well, I will furnish the San Joaquin Local Health District a <br /> k WELL DRILLERS REPORT of thewell 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 TOG QUTING FIN L I5SPF.,TION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY i <br /> t ADDITIONAL COMMENTS: �} PHAS ISI/FIN INSPECTION <br /> PHASE II GROUTIIN ECTION <br /> ' INSPECTION BY [DATE INSPECTION BY DATE 7i <br /> 2M / <br />