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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. o� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued CJ �7 <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 an the Rules nd :ReZlat <br /> ' ns of the San Joaquin Local Health District. <br /> ESS <br /> JOB AD K /LOCAT,1AI CENSUS TRACT <br /> Owner's,Name J' PhoneZZ <br /> , <br /> Addres City <br /> Contractor's ].�me License # 4"21 Phone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / 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 <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 o Grout Seal <br /> Cathodic Protection Rotary Type of t <br /> Disposal Other Other Informat ,-.,,___ __-_ <br /> Geophysical Surface Seal Installed By: <br /> PUMA' INSTALLATION: Contractor <br /> Type of Pump ���� �� ,6/� H.P. <br /> PUMP REPLACEMENT: / / State Work Done A <br /> PUMP .REPAIR: / State Work Done � �42 T <br /> V � <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 kno dg and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR241UG AND A FINAL INSPE <br /> SIGNED aZfTLE <br /> (DRA PL P ON RE RSE SIDES) <br /> F DEPARTMENT USE ONLY <br /> PHASE I [� <br /> APPLICATION ACCEPTED n <br /> DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE Ii GR NSPECTION PHASE I/ INAL INSPECTION I <br /> INSPECTION BY DATE INSPECTION BY ,-- DATE Q P 7 <br /> 0/77 _ 2M <br /> E H 1426 Rev. . 1-74 - <br />