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N V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&;OFFICE USE.. V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name P Phone , <br /> Address <br /> ' City .' <br /> Contractor's Name t J License # Phone 0 <br /> TYPE- OF WORK (Check) : NEW WELL/_7 DEEPEN /? RECONDITION f_7 DESTRUCTION /_7 <br /> PUMP INSTALLA7CION PUMP REPAIR -/-7—PUMP REPLACEMENT F7 <br /> Other bCC/�/. <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 /> T _ Cathodic Protection t Rotary _Type_o_f_Grout <br /> Disposal Other Other Information { <br /> Geophysical <br /> Surface Seal Installed Bvi I <br /> PUMP INSTALLATION: ' ' 'Contractor ...., <br /> _ Type of• Pump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP:AFFAIR jAAX <br /> State Work Dane <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 Califo;rnia' pertaining to or regulating well construction. ' Within FIFTEEN DAYS <br /> after completion of my'faork on a new well, I will furnish the San Joaquin 'Loca1 Health District a 1 <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 CALVFORGROUT INSPECTION <br /> PRIOR TO GRQ ING AND A NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ; <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. 'Sy DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I INSPECT N <br /> IN'SPECTION .BY DATE INSPECTION BY DATE <br /> g H 1426 Rev. 1-74 <br />