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SAN JOAQUIN LOCAL HEALTH DISfAICT <br /> 16 <br /> FOP OFFICE USE: 01 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 c <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t $ �'/ ;' .,Xy 0�1 CENSUS TRACT <br /> Owner's Name t !� Phone <br /> Address City <br /> Contractor's Name el License Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /,!q/ PUMP REPLACEMENT /-7 <br /> Other <br /> f. <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 /> T Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation =Gravel Pack, Depth of Grout Seal <br /> Cathodic Protection 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• l <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: . State Work Done _ G <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-bes f m kno ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL NS <br /> SIGNED TITLE <br /> D W -PLOT PL RE ELSE SIDE ; <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . /� DATE — 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - - 7 <br /> � � 4 <br /> 3/76 2M x <br /> E H 1426 ,Rev., 1-74 _� <br />