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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—R70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR.WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6'r/S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE__ISSUED .Date Issued �G <br /> (Complete In Triplicate) � <br /> Application is hereby made to the San Joaquin Local llealth Dietkct 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 Phone <br /> p <br /> Address City <br /> Contractor's Name License l 4� J)3 Phone 66 <br /> TYPE OF WORK (Check) : NEW WELL. /_7 DEEPEN '/? RECONDITION %j. DESTRUCTION f7 , <br /> PUMP INSTALLATION/ / PUMP REPAIR/7 PUMP REPLACEMENT f7 <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 U� <br /> Industrial Cable Tool Dia. of Well Excavation G1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> -Domestic/public Driven Gauge of Casing 6� <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 /> Type -of Pump H.P. <br /> PUMP REPLACEMENT: / / 'State Work Done <br /> PUMP 'REPAIR; State Work Done p a. <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 true to the•best.of- my. knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION. <br /> SIGNED . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FININSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E:H 1426 <br /> Rev. 1-74 r. ._ - _ _ -.l�L75 -- � <br />