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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -FO-Fl-"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> E <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 /> f County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,LA.;a� CENSUS TRACT <br /> r <br /> Owner's Name i (.:/,c.�'Q _ Phone t' / •i <br /> Address Q Q . . <br /> City j"s—A <br /> Contractor's Name License Phone3� <br /> I � <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTAL TION/ / PUMP PAIR / / PUMP REPLACEMENT /� <br /> Other — <br /> f 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 /> F 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 d <br /> t Irri ati.on Gravel.'Pack Depth-of-Grout Seal <br /> Cathodic Protection ' Rotary Type of Grout <br /> F ^ Disposal Other `Other Information <br /> Geophysical 'n Surface Seal Installed By: <br /> A PUMP' INSTALLATION: Contractor �J <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT:" —/ / 'Statd-'Work Dome"" <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 construction. Within FIFTEEN DAYS <br /> j after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> F WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informatio s true to the best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GAQrfJTIW AND NAL INS CTION. <br /> SIGNED TITLE <br /> DRAW PL T' PLAN ON REVERSE SIDE i. "':„ <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE Z�r <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: 0 ' <br /> PHASE II :GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />