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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-5781 . � <br /> fAPPLICATION 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 applicati6n" 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 /> CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION y' <br /> Owners Name G Phone 1 �� <br /> r. <br /> Address . City <br /> V 4f <br /> Contractor's Name License # 13,,3Phone hC r <br /> TYPE OF WORK (Check) : NEW WELL .• DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other '/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK g_ SEWER LINES PIT PRIVY <br /> - _ SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> . PROPERTY LINE - PRIVATE bomESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE' TYPE OF WELL CONSTRUCTION SPECIFICATIONS'' <br /> Industrial Cable Tool Dia. of Well Excavation Z10 " <br /> Domestic private — Drilled Dia. of Well Casing <br /> Domestic/public 'Driven Gauge of Casing ! <br /> Irrigation Gravel Pack Depth of Grout Seal -4 ' y <br /> _ - Cathodic Protection )C Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor deg;�;� - !7� <br /> Type of Pump H.P. / -- <br /> PUMP REPLACEMENT: / / State Work Done 1 <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 /> 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 Arue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT G 4ED A AL INSP ION. <br /> TITLE IJA <br /> SIGNED W PT T PLAN ON REVERSE SIRE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IA/ <br /> APPLICATION ACCEPTED BY DATE - <br /> ', ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IITjFINA1 INSPECT O <br /> INSPECTION BY DATE INSPECTION BY t DATE <br /> E H 1426 Rev. 1-74 <br /> .. . 3/76 7M <br />