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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE` USE: 1601 E. Hazelton,Ave. , Stockton, Calif. <br /> I Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .5'e) 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued <br /> I . (Complete In Triplicate) . <br /> Application is hereby made toithe San Joaquin Local Health District for a permit to construct r <br /> and/or install .the. work hereitri. described. This application is -made in compliance with. San-Joaquini <br /> County Ordinance No.• I862.,.and the. Rules and Regulations of . the San Joaquin. Local Health District. ; <br /> JO � <br /> j ADDRESS/LOCATION . CENSUS TRACT <br /> Owner's Name 7 Phone <br /> Address <br /> City <br /> Contractor's Name f- ? License /.7 �, 3 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /; / — <br /> DISTANCE TO NEAREST: SEPTIC TANK/Ap-jP- SEWER LINES �Lj�.� PIT PRIVY <br /> SEWAGE DiISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> PROPERTYLINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS + <br /> Industrial (j Cable Tool Dia. of Well Excavation <br /> Domestic/private _ Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ;1 Gravel Pack Depth of Grout Seal ) <br /> Cathodic Protection 1 V Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> G .. <br /> PUMP INSTALLATION: <br /> Contractor .� <br /> Type of 'Pump H.P. «• <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well D �meter 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 theASan 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 f <br />'RIOR 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 /> kPPLICATION ACCEPTED BY DATE �f <br /> UDITIONAL COMMENTS: <br /> P E II GROUT INS TION PHASE III/F NAL INSPECTION <br /> LNSPECTION BY DATE INSPECTIONBY DATE ��-� <br /> E H -14.2.6-�. Rev.... -74 I3 '�/`7 _ 2I <br />