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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORFF][GE-- USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7/- W <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 Distridt. <br /> JOB ADDRESS/LOCATION /i Q -e CENSUS TRACT <br /> Owner's Name 8 YL � ) Pf Phone <br /> Address _ _ c� C�- �z City ' . <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL.-L-7 DEEPEN '/_7 RECONDITION f7 DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR -/-7-pump REPLACEMENT /J <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES', : r 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 /> Industrial Cable Tool Dia. of Well Excavation (� <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B -� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 4 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMPP ,.REPA;LR: /7 State Work Done <br /> DESTRTRUUCTION OF WELL: Well Diameter Approximate Depth f� <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, C41tL FOR A GROUT INSPECTION <br /> PRIOR TO q&% NG AND -IN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF,,IjI FINAL INSPECTION <br /> INSPECTION BY -DATE INSPECTION BY DATE � <br /> E H 1426 Rev. 1-74 - -- h/75 -2M <br />