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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: If-01 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 7dl-]7 <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q CENSUS TRACT <br /> w <br /> Owner's Name Phone <br /> Address City +` <br /> Cont`ractor's Name License Phone . <br /> TYPE OF 146RK (Check) :, NEW>WELL / / DEEPEN -/ / RECONDITION / / DESTRUCTION I�T <br /> ' *`$ i PUMP :INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> . ,1 <br /> ,r / µ <br /> Other `1 <br /> . DISTANCE TO'lNEAREST.:. SEPTIC TANK SEWER LINES PIT PRIVY <br /> -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> of PROPERTY LINE - PRIVATE DOMESTIC WELL ^ PUBLIC DOMESTIC WELL <br /> INTENDED USE 'f TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �' Cable Tool Dia. of Well Excavation <br /> rivate Drilled Dia. of Domestic/private f Well Casing _ <br /> Domestic/public Driven Gauge of Casing <br /> Gravel Pack Depth A,Grout Seal <br /> Irrigation � O <br /> Cathodic Protection- ;` RotaryType ofd Grout <br /> Disposal �-; , Other ' ( Other Information �- <br /> Geophysical ` ' ;~ Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ . 1 H.P. �} <br /> PUMP REPLACEMENT: / /- State Work Done <br /> PUMP .REPAIR: K^_ State Work Done <br /> Approximate Depth - <br /> ODES;TRUCTION OF WELL: Well Diameter <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 GROWING AND A F L I PEC ION. <br /> SIGNED ti- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> , APPLICATION ACCEPTED BY <br /> :` ADDITIONAL COMMENTS: <br /> PHASE II ROUTwINSPECTION PHAS IT . FINAL INSPECT�ON �' <br /> INSPECTION BY DATE INSPECTION BY DATE , <br /> r <br /> r-r <br /> 1177 _ 2M <br /> F. H 1L26 Ra_v. 1-74 � <br />