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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR+raFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> a APPLICATION FOR WELL CONSTkUCTZON OR rump PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 .YEAR PROM DATE ISSUED Date Issued <br /> . (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Disttict 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 S n Joaquin Local Health Aim t�r,�ct, <br /> JOB ADDRESS/LOCATION iGc� - "` <br /> - CENSUS TRACT <br /> Owner's Name 21Phone <br /> Address F City a <br /> Contractor's Name ✓� / C License # Phone <br /> TYPE OF WORK (Check) NEW WELL /_]" DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION V7 PUMP REPAIR /7 PUMP REPLACEMENT FT <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 <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: Contractorf� <br /> Type of Pump H.P. j <br /> PUMP REPLACEMENT: /—/ State Work Done <br /> PUMP !REPAIR: /_7 State Work Done <br /> ES'PRUCTION OF WEZL: 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 <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 OR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F AL INSPECTION. <br /> SIGNED TITLE <br /> '(DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _- DATE d <br /> ADDITIONAL COMMENTS: e r <br /> PHASE II GROUT INSPECTION PHASE IIIIFINAI,,INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 ZM <br />