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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBfOFFICE USE: 1601 E. Hazelton: Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICKTION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &(;--7G <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construe <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 /> .TOB ADDRESS/LOCATION s !r✓s,,r ��-ms:.✓,�� /' f � S. � CENSUS TRACT � <br /> Owner's Name Phone <br /> Address City L � <br /> Contractor's Name License - l� 3 2 Phone31,k rk34 <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR ' PUMP REPLACEMENT /7 <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By,, _ <br /> PUMP INSTALLATION: Contractor ,v •� <br /> Type of Pump H.P. <br /> <;t � <br /> PUMP REPLACEMENT: / / _ State Work Done _ _..... _ <br /> PUMP :REPAIR: State Work Done ' ;��► .� <br /> ES•TRUCTION 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 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, GROU G D A FNA INSPECTI N. <br /> SIGNED TITLE <br /> (DRAW PLAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> .*AP,PL TION`--ACCL'gTED BY DATE 11,2 <br /> ADDITIONAL COMMENTS: . <br /> � •PHASE II . ROUT INSPECTION PHASE Y114tINALINSPEC ON <br /> INSPECTIOp.,BY,' DATE INSPECTION BY DATE <br /> 1 E•H 1426 Rev. --1774 1-74 2M <br /> .- <br />