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✓� SAN JOAQUIN LOCAL HEALTH DISTRICT t1l Ali �7 <br /> 0& 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 1 YEAR FROM DATE ISSUED Date Issued <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 - L CENSUS TRACT <br /> Owner'a Name 67 C/C <br /> Phone ��,�,-- .SS" <br /> Address _ (p <br /> City 51� <br /> Contractor's Name License # . Phone <br /> TYPE OF WORK (Check) : NEW WELL -/7 DEEPEN -/-7 RECONDITION /-7 DESTRUCTION f7 , <br /> PUMP INSTALLATION �` PUMP REPAIR/? PUMP REPLACEMENT /-7 <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 /> Doviestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing V <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> p Other Other Information .. <br /> Geophysical Surface Seal Installed B -� <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> PUMP REPAIR: State Work Done X': <br /> DES•T, RUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and. Procedure 4- <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local health District Ir <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' i <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 O ING SPECTIO � <br /> SIGNED TITLE <br /> (DRAW PLOT LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS TION PHAS FINAL INSPECTIO j <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 oil, 2M <br />