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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. I?clo-,14 <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 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 Uf CENSUS TRACT <br /> Owner's Name Phone <br /> Address v City ��,�-�, <br /> Contractor's Name C tte. License # Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /_7 RECONDITION /_7 DESTRUCTION f <br /> PUMP INSTAL TION /—/­PUMP REPAIR /7 PUMP REPLACEMENT s <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAINK V SEWER INES 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 filled Dia. of Well -Casing <br /> Domestic/public Driven Gauge of Casing IJ 7+ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophys cal Surface Seal Installed BY: p, <br /> PUMP INSTALIATION:j Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /-7 State Work Done <br /> ,SES®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 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 GROUTING AND A FINAL INSPECTION. <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 /> PHASE II GROUT INSPECTION P FIMVINSPECT105 <br /> INSPECTION BY DATE INSPECTION M DAT <br /> E H 1426 Rev. 1-74 /� 1-74 2M <br />