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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;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 /> (Camplete 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO <br /> t <br /> CENSUS TRACT <br /> Owner's Name t <br /> Phone ' <br /> Address r <br /> Ci <br /> Contractor's Name ^ License phone 17 <br /> TYPE OF WORK (Check) : NEW WELL -7 DEEPEN ' <br /> _/r7' RECONDITION /7 DESTRUCTIONf <br /> PUMP INSTALLATION / / PUMP REPAIR _7PUMP REPLACEMENT /? <br /> Other /_7 bl <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 , Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> sal <br /> Cathodic F'rotectian Rata <br /> r <br /> Disposal. - Other Type of Grout <br /> Geophysical A. --- Other Information <br /> Surf ace Seal Installed B <br /> PUMP INSTALLATION: <br /> Contractor ! <br /> Type .of Pump I <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP '.REPAIR: <br /> / / :State Work Done . . . ^� <br /> I <br /> DESTRUCTION OF WELL: Well Diameter <br /> Descri>e Material and Procedure APPoximate Depth <br /> " } <br /> I hereby agree to comply with all laws and regulations of the San Joa uin Local H <br /> And the State of California pertaining to:or re ulatin t ealth District <br /> .S g we11''canstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, x will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them be€ore putting.. the..well. in.use.... The above <br /> information is true to the and belief. I WILL CALL FOR A 'GROUT INSPECTION } <br /> PRIOR TO GROUTING AND A FINAL PECTiON. <br /> SIGNED �- TITLE J <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I <br /> ` A FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY P III F AL INSPECTION <br /> DATE INSPECTION B -DATE �S <br /> E H 1426 Rev. 1-74 _-- <br />