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'SAN JOAQUIN LOCAL HEALTH -DISTRICT <br /> FOk OFFICE USE: 1.601 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 le 7V <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit Ca 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 I �, I j , � -- - - CENSUS TRACT <br /> f: <br /> Owner's Name' r Phone <br /> Address City <br /> Contractor's NameL License IMhone &6mlld,3' <br /> i{ <br /> I <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION UMP 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 WELT, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Viable Tool Dia. of Well Excavation � <br /> omestic/private Drilled Dia. of Well Casing _ floe <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> i <br /> Cathodic Protection Rotary :Type ofiGrout ; <br /> Disposal Other r Other Information ! <br /> Geophysical Surface Seal'Installed B : <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. / / State Work Done <br /> ! <br /> PUMP ,.REPAIR: / ./ State Work Done <br /> DESTRUCTION_ OF WELL: '. Well Diameter 4 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 GROU INSPECTION <br /> PRIOR TO CpaOUTINaAft A Fj2AL 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 PHV§& I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ..� <br /> 1177 2M�O <br /> E H 1426 Rev. 1-74 - - -- — _ - <br />