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�N_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOErOFFICE�USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ='• Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S__ <br /> ,S"� <br /> THIS .PERMIT EXPIRES 1• YEAR FROM DATE­ISSUED Date Issued , �_ 2 <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/LQCATIO CENSUS TRACT" <br /> Owner's Name <br /> Phone <br /> Address T City <br /> Contractor's Name ,License # / Phone <br /> TYPE OF WORK (Check): NEW WELL /-,DEEPEN /_' RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR 1_7—Pump '_REPLACEMENT %f .,_ *� <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK�_LL�& SEWER LINES a i'v PIT PRIVY . <br /> SEWAGE DISPOSAlf FIELD C SSPOOL/.SEEPAGE PIT OTHER CN <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL --�i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> VIndustrial Cable Tool Dia. of Well Excavation fi <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 /> F ,rS�.� "' — <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> I <br /> PUMP :-REPAI-R: /- State• Work Done <br /> E&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 neva 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 FOR A GROUT INSPECTION <br /> PRIOR TOG UTING .AND" F AL INSPE ION. <br /> SIGNED <br /> TITLE <br /> (DRAW P P N REVERSE SIDE .4 <br /> F DEPARTMENT USE ONLY <br /> PRASE I � � <br /> A P A ION ACCEPTED BY DATE <br /> ADDIkONAL COMMENTS: <br /> i F , P E I GROUT INSPECT ON <br /> P E I FINAL INSPECTION <br /> INSPECT �JN 'BY. DATE INSPECTION BY DATEq-10-1- <br /> E H 1426 ': ;Re '",1-74 _ `r <br /> 1-74 2M - <br />