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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF 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 <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, C CENSUS TRACT <br /> Owner's Name Phone ,z /014go <br /> Address <br /> Cityoac-­Op c <br /> Contractor's Name Aj, .—License Phone <br /> TYPE OF WORK (Check) : NEW WELL T DEEPEN/ / RECONDITION /_/ DESTRUCTION /7 s <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK -t SEWER LINES /60` - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT --1 OTHER <br /> PROPERTY LINE/Q'PRIVATE DOMESTIC WELL � PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial - Cable Tool Dia. of Well Excavation _ �_2 �r _ <br /> +! Domestic/private Drilled Dia. of Well Casing .4 � <br /> Domestic/public Driven Gauge of Casing. " <br /> Irrigation Gravel Pack Depth of Grout Seal �j� � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information � <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type-of Pump _. H.P. <br /> L 1 <br /> PUMP REPLACEMENT: /�/ State Work Done <br />'PUMP .REPAIR: / / State"Wdrk Done <br /> DES•TR_UCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with alA 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 /> informati is true to the 's of 6y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G G A FI SP 0, <br /> SIGNED TITLE <br /> F <br /> (DRAW PLOT PLAN ON REVERSESIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY l DATE- I <br /> ADDITIONAL COMMENTS: <br /> PHASE TI OUT INSPECTIO �ie. y- _,_,PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - —INSPECTION BY DATE _ f - 77 <br /> 1 r�'Z7 <br /> E H 1426 Rev. 1-74 ° '� <br />