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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :FOR OFFICE USE: 1.601 E. Hazelton Ave.. , Stockton, Calif. <br />' Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ! v <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 incompliance with San Joaquin; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 9- + CENSUS TRACT. i <br /> Owner's Name ' <br /> Phone <br /> Address q <br /> City , 3 <br /> a <br /> Contractor's NameJ Licensehone Lr <br /> TYPE OF WORK (Check) : NEW WELL )i�F DEEPEN / / RECONDITION /_/ DESTRUCTION /7 ; <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 #� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES j' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL 10- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> . Industrial Cable Tool Dia. of Well Excavation <br /> /Domestic/private _ Drilled Dia. of Well Casing <br /> oe- <br /> Domestic/public Driven Gauge of Casing <br /> 41 <br /> Irrigation eGravel Pack Depth of Crout Sea <br /> Cathodic Protection V Rotary Type of Grout <br /> ]Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DES-' RUCTION 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 thewell 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 GROUTING AND A FINAL INSPECTION, W <br /> SIGNED TITLE <br /> (DRAW PLOT_PLAN ON REVERSE SIDE) " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHAS III/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - v <br /> E H 1426 Rev. - I-74 �� b/77 2M <br />