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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOOFF:ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br />' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `/p /0 <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 CENSUS TRACT <br /> Owner's Name Phone <br /> Address C7 �» <br /> _ City .Cli�.r► S <br /> Contractor's Name _ License Phone / <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE -- PAIVATE. DOMESTIC WELL PUBLIC DOMESTIC WELL rr.. <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> L./f 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 By: <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: jJ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DE5, TION 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 FOR A GROUT INSPECTION <br /> PRIOR TO G IN D A FINAL INSPFoCTIOJI. . <br /> SIGNED Z e TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL:, COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS&,,III/FIDJAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE g—_,T_--7 7 <br /> E H 1426 Rev. 1-74 �� 7 - 2M <br />