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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- 3'/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 f the San Joaquin Local Health District. <br /> 350 6 <br /> JOB ADDRESS/LOCATION - z CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name _ License M5� hone 2= <br /> C t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES b - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> Industrial Cable Tool Dia. of Well Excavation _ J <br /> Domestic/private 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 l <br /> Disposal Other Other Information 1 <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 GD&TING A ZIUL INSPECTION. <br /> SIGNED TITLE <br /> DRAWPE T PLAN 'ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �fJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 6 .]46 INSPECTION BY DATE - 7 <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />