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FOF�rO 'FICE USE• SAN JOAQUIN LOCALHEALTH DISTRICT - <br /> // 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (249) 456-6782 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��_�,p� <br /> t 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 71/- 41-",10 <br /> Date Issued <br /> ( C <br /> Application is hereby made to the San Joaquin Local Health District foreersn <br /> it <br /> and/or install the work herein described. This application is made in compliancetwithnSan uJoaquin <br /> County Ordinance No. 1862 anis the Rules and Regulations of the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION <br /> CENSUS 'TRACT <br /> Owner's Name <br /> Address <br /> Phone Le <br /> `' <br /> City ` <br /> Contractor's Name - i <br /> License ttkt Phone <br /> F <br /> TYPE OF WORK (Check): NEW WELL �/�DEEPEN ' _ Y <br /> /� RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION /�./� REPAIR /—/ PUMP REPLACEMENT <br /> Other IS/- /? IIf <br /> DISTANCE TO NEAREST: f <br /> SEPTIC TANK SEWER LINES PIT PRIVY k <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ` { <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> TYPE OF WELL <br /> InduCONSTRUCTION SPECIFICATIONS <br /> r strial Viable Tool Dia. o£ Well Excavation <br /> ;Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public � r <br /> Irrigation ----� Driven Gauge of Casing <br /> t Gravel Pack Depth of Grout <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other - i <br /> Geophysical ®they Information . <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor � f <br /> Type of Pump <br /> PUMP REPLACEMENT: H.P. <br /> S ate Work Done <br /> Pte' !REPAIR: /? State Work Done. <br />, ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 I <br /> WELL DRILLERS REPORT of the well and notify them before putting. the. well in use. The above <br /> rict a <br /> information is true to the-besi of- my knowledge and belief, <br /> A FINSPECTION. I WILL GALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND N <br /> SIGNED 4 � � <br /> TITLE f <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) - — <br /> PHASE I FOR DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED By <br /> ADDITIONAL COMMENTS: DATE d f <br /> PHASE II GROUT .INSPECTION <br /> INSPECTION BY DATE / /i INSPECTION BYHASE III FINAL INSPECTION <br /> 1. DATE <br /> E H 1426 Rev. 1-74 <br />