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FOR76FFICE�USE• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> . Lr> <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to con <br /> and/or install the work herein described. This application is made in compliance with San <br /> Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/I� L�1 riot. <br /> Owner's Name CENSUS TRACT <br /> Address Phone <br /> City <br /> Contractor's Name 0iS <br /> License , Phone�;��� f� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN <br /> PUMP INSTAyLATION /-7UMP REPAIR L-7 PUMPERRPLA IEMEN� <br /> Other / / /7 <br /> DISTANCE TQ NEAREST: SEPTIC TANK <br /> SEWER LINES 4 PIT PRIVY *— <br /> SEWAGE DISPOS FIELD "~ CESSPOOL/SEEPAGE PIT <br /> PROPERTY LTNE� RIVA DOMESTIC WELL '�dPUBLIC DOMESTIC 6:2 41 OTHER. <br /> INTENDED USE TYPE OF WELL IC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Cable Tool Dia. of Well Excavation <br /> Domestic Drilled Dia. of Well Casing <br /> -- /public Driven Gauge of Ca <br /> Irrigation �� Gravel Pack sing <br /> Cathodic Protection Depth of Grout Sesl �-r,4siis <br /> Disposal ,�,r_ Rotary Type .of Grout <br /> Other <br /> Geophysical Other Information <br /> _ � ------�. <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump Aaft-!2� <br /> H.P. --- <br /> PUMP REPLACEMENNT: j/ / State Work Done <br /> PUMP '.REPAIR: /? State Work Done <br /> ES•TR[TCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> --.--, <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 an a new well, I will furnish the San Joaquin Local Health District e <br /> WELL DRILLERS REPORT of the well and notify them before <br /> information is true to the best of- my knowledge and belief. I Putting the-well in use.. a above .. <br />?RIOR TO GROUTING AND A FINAL TNSPECTTONWILL CALL OR AGROUT <br /> . INSPECTION <br /> 5TGNED <br /> DRAW PLOT PLAN ON REVERSETLE SID <br />'RASE I FOR DEPARTMENT USE ONLY <br /> IFPLICATION ACCEPTED BY ` <br /> WDITIONAL COMMENTS: DATE 7tir <br /> PHASE II GROUT INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE c/� INSPECTION By <br /> DATE <br /> E H 1426 Rev. 1-74 <br />