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' tSAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOS 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 _='� ail CENSUS TRACT r <br /> Owner's Name Phone <br /> Address P <br /> city <br /> Contractor's Name License # 1� �3 Phoneb b 9ba� <br /> ' a <br /> TYPE OF WORK (Check) : NEW WELL DEE PEN I R/RECONDITIO.N.. / DESTRUCTION <br /> AL <br /> PUMP INSTLATION '/ I PUMP REPAI !,J PUMP REPLACEMENT 17 <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 /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �u <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal I Other Other Information ' <br /> _ Geophysical Surface .Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type orf Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP;REPAIR:-. .,.— -f.!/ .. State.Work_Done..- U, <br /> DESTRUCTION OF WELL: Well Diameter ° R Approximate Depth <br /> i <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 /> informationjis true to the best of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAWPL T PLAN ON REVERSE SIDE <br /> P , <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> j PHASE I W <br /> APPLICATION ACCEPTED BY DATE - ',74' <br /> _ <br /> ADDITIONAL COMMENTS: # <br /> PHASV II GROUT-INSPECTION PHAS I I F NAL INSPECTION <br /> INSPECTTON BY + DATE <br /> INSPECTION BY DATE 7 77 2G <br />�. E ,H 1426 Rev. 1-74 3/76 2M <br />