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y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �,- Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 3 ; vPermit No. 2ti_ 5�a,_ <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 /> 1 <br /> Owner's Name J_ Phone <br /> Address City <br /> Contractor's Name SCJ License 4��lhone <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN /_/ " RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT <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 v <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection `: Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br />` <br /> Type of Pump H.P. • ./ <br /> y I; <br /> 4 PUMP %rc% ' State Work Done ® (7 �l <br /> PUMP .REPAIR: P/ State Work Done <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 /> r information is true to the best of my. ow a an elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G NG AND A FINAL IO . 17 <br /> SIGNED TITLE �f' <br /> D . F LAN 'ON FRSE SIDE) 1"t-1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ` PHASE II GROUT INSPECTION PHASE III/F AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION. BY DATE <br /> - '7f2m <br /> ;,_ _.E H 1426 Rev. 1-74, <br />