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SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> FOt� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _/02/&) <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 CENSUS TRACT <br /> Owner's Name t <br /> Phone & <br /> ., <br /> Address City.' <br /> Contractor's Name License 0�Gaz Phone K,:-'-L� ? <br /> TYk OF WORK (Check): NEW WELL. DEEPEN -/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/_7 PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE.- PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS R� <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 /> Cathodic Protection Rotary Type of Grout F <br /> =Disposal Other Other Information.' ' <br /> Geophysical Surface Seal In'stalled'B <br /> .PUMP INSTALLATION: _ l <br /> Contractor <br /> _ Type of Pump H.P. <br /> PUMP REPLACEMENT: . j_/ State Work Done, ' <br /> PUMP 'REPAIR: State Work Done j <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 tr- �to the-best-of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR U?NG D 4WAL INSPECTION. <br /> SIGNED TITLE <br /> ell (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPL;CATION- ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS .III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �fjsZg6 <br />