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SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> FOE OFFICE USE: 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 ?-5- <br /> (Complete In Triplicate) <br /> Application is Aereby 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 a d the Rule and Regulation of the San Joaquin Local Health- District. <br /> JOB ADDRESS/L T <br /> CENSUS TRACT <br /> Owner's t <br /> Phone <br /> Address <br /> a-. Cit <br /> Contractor's Name License q� � hone � <br /> TYPE OF WORK (Check) :. NEW WELL / / DEEPEN /7 RECONDITION 7. DESTRUCTIONS/� -` <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 /> 1 Industrial Cable Tool Dia, of Well Excavation " <br /> Domestic/private Drilled �..;, <br /> Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Graveh Pack Depth of Grout Seal \ <br /> � + <br /> Cathodic Protection Rotary Type of Grout <br /> .Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> PUMP .REPAIR: " <br /> State Work Done _ <br /> DESmiRUCTION OF WELL: Well Diameter t Approximate Depth <br /> i 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 4 <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 /> iDR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> _ TITLE r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />?LASE I <br /> WPETCATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N - T " <br /> INSPECTION BY DATE INSPk:CTZON BY DATE <br />_E.H 1426 Rev. 1 -74 o 177 2M <br />