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SAN JOAQUIN LOCAL REALTH DISTRICT <br /> 0W OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued7S- <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 <br /> ENSUS TRACT <br /> Owner°s Name f Phone�(� I �� <br /> Address / <br /> City <br /> Contractor's Name <br /> . _�. _License, �. s�,-0 <br /> 32 . g <br /> r <br /> TYPE OF WORK (Check): NEW WELL, /-7 DEEPEN /_7 RECONDITION <br /> /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR IS;T PUMP REPLACEMENT /7 <br /> Other L-1 <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 3 <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 (�n <br /> Domestic/private Drilled Diai-*of Well Casing ( <br /> Dol stic/public Driven Gaugd''of Casing <br /> ,,Irrigation \ Gravel Pack Depth of Grout Seal <br /> ,_ Protection- <br /> �Cathodic Protection= �} - - Rotary - - Type -o.f Grout' <br /> Disposal t Other Other Informatidn <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor /V <br /> Type of Pump _. ., - ._�._ H.P. <br /> ...._ <br /> PUMP REPLACEMENT: . <br /> /, / _State, Work Done <br /> .REPAIR: State.Work Done 4_� <br /> E&TRUCTIQN OF WELL: Well Diameter Approximate Depth <br /> Pp P <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 r <br /> WELL DRILLERS REPORT of the well,and notifythem before <br /> putting the well in.use. The above <br /> information is true to the best of. m - knowledge and belief. I WILL CALL FORA -GROUT INSPECTION <br /> PRIOR TO GWMTINleg AND NAL INSPEj6rION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE : i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE //—a<j <br /> ADDITIONAL. COMMENTS: <br /> PHASE II T N, EMOV PHASE Ib INAL INSPECTION <br /> INSPECTION BY DATE Ll INSPECTION DATE <br /> E H 1416 Rev. I-74 J 1-74 2M t <br />