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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pdrmit No.,7(___�_�;L�1a <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 of the San Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION (nAll �7 CENSUS TRACT <br /> Owner's Name e/ Phone ym <br /> Address a,2OJ00a City <br /> Contractors Name • , S_`� -} rel License #o2,-,2y1i7 Phone g <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/? RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION/—/ PUMP REPAIR'/ / PUMP REPLACEMENT %T <br /> Othei-%// <br /> s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 4 <br /> PROPERTY LINE _ PRIMATE DOMESTIC WELL' :--L PUBLIC DOMESTIC WELL ^� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation `k <br /> Domestic/private Drilled Dia. of Well Casing A. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack- Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other In£orianation <br /> Geophysical `.--.. Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> _ n <br /> Type sof Pump H.P. <br /> PUMP" REPLACEMENT % / State Work Done <br /> PUMP .REPAIR: / f- State Work Done <br /> - <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 FO 'A GROUT INSPECTION <br /> PRIOR TO GROUT NG AND A FINg INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SInA <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .... ` +' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE 'II GROUT INSPECTION PHASE III AL INSPECT1 <br /> INSPECTION BY DATE INSPECTION BY DATE <br />