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' SAN JOAQUIN LOCAL HEALTH DISTRICT k <br /> FOE OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made ,toIthe 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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i ® ~' q CENSUS TRACT <br /> Owner's Name Phone <br /> Address ea s.� City ti <br /> w <br /> Contractor's Name 154 9� License Phone <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION `—PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / 1 <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 1� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia, of Well Excavation <br /> [--Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal i Other Other Information ! <br /> Geophysical ! Surface Seal -Installed B <br /> PUMP INSTALLATION: Contractor .P� i-�� <br /> Type of Pump H.P. <br /> { —--- <br /> PUMP REPLACEMENT:_ �I State Work Done e-4�? �d <br /> PUMP .REPAIR: / / State- Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <br /> 1 <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 notify them before putting thewell in use. The above <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ' ► TITLE l <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE '� 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC N P�W.AIIIFIYALINSPE T N r <br /> INSPECTION BY DATE INSPECTION DATE <br /> E H 1426 i2Pv. 1-7A <br /> U77 2M <br />