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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> i7 Stockton Calif. <br /> FOF� OFFICE USE: 1601 E. Hazelton Ave. , > <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 T <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. <br /> This <br /> application <br /> this e Saecompliance <br /> San Joaquin <br /> County Ordinance No. 18b2 and the Rules and Regulations <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION d <br /> Owner's Name L. / f 1 Phone <br /> City .S <br /> Address <br /> License P1Phone <br /> Contractor's Name <br /> TYPE OF WORK�(Check) : _~NEW WELL /17--DEEPEN / / RECONDITION / pEPLACEMENT7/-T <br /> PUMP INSTALLATION/�� REPAIR ./—/ -- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK L Or- SEWER LINES PITT 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 ste le Tool Dia. of Well Excavatione� N,t___-D"amestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea �d <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other. Information <br /> Geophysical Surface Seal Installed S <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <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'constructiQn. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District s <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 GROU ING D A FINAL INSPECTION. <br /> SIGNED 00, <br /> TITLE <br /> (DRAW.PD T PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE F INSPECTION <br /> P 1l.IfVSPECT 0 DATE <br /> INSPECTION BY DATE INSPECTION BY <br /> 2M <br /> E:"H..1426 <br />