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`. SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE <br /> 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 <br /> the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Al CENSUS TRACT <br /> k Phone <br /> Owner's Name <br /> Address City / <br /> Contractor's Name License �� 7'Phone <br /> i• <br /> ) <br /> ( <br /> TYPE OF (Check) : 'NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION //_7 <br /> PUMP INST LATION /�./ PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other '/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \'r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br /> Cable Tool Dia. of Well Excavation <br /> Industrial !� <br /> Dia. of Well Casing <br /> Domestic/private Drilled <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of-'+Grout Seal475 . <br /> Cathodic Protection, Rotary Type of Grout T <br /> Disposal Other Other Information <br /> f Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 0i H.P. <br /> i <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> i <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 true to the best of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GF109TING AND A FINAL NSPECTION. <br /> SIGNED TITLE <br /> ,..-. ,•; is <br /> D W. PIS T PLAN''ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE -? 77 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS ROUT NSPECTION PHASE I/FIN .L INSPECTI N � <br /> INSPECTION BY . ATE 7 INSPECTION BY DATE z <br /> pwax <br /> 2M <br /> F K 1L9A Rav_ 1-74 <br />