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SAN JOAQUIN LOCAL. HEALTH DISTRICT , <br /> EOE OFFICE USE; ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No;7f— <br />{ <br />` THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issue <br /> (Complete <br /> Application is Aereby made to the San Joaquin Local Health District for aermit <br /> p 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 DistO ct. <br /> JOB ADDRESS/LOCATION ��j CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City.- <br /> Contractor's Name License it-fjQf Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /—/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION <br /> Other % <br /> PUMP REPAIR / / PUMP REPLACEMENT <br /> - / <br /> DISTANCE TO NEAREST; SEPTIC TANK ;�a�. SEWER LINES ! PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT BOTHER ell � <br /> PROPERTY LINE X4RIVATE 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 " ff <br /> Domestic/public Driven Gauge of Casing lgc"C" ! <br /> Irrigation 'Gravel Pack '"""'"!Depth of Grout Seal . <br /> Cathodic Protection Rotary Type of Grout v ,� <br /> Disposal-*- •..gym. -x Other Infor ` <br /> OCYi'e`r mation - <br /> Geophysical <br /> 4—,_ _ Surf lice•Seal__InstalJed <br /> PUMP INSTALLATION: Contractor f ) <br /> Type of P , <br /> ump �= H.P. �= <br /> PUMP REPLACEMENT / / State Work Done <br /> r <br /> PUMP .REPAIR: State.Work Done 4 <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 n a new well, I will. furnish the San Joaquin Local Health District-. a <br /> WELL DRILLERS REPORT of a well and notify them before putting the well in use. The above ` <br /> informatio s~-tr,ue the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG MITI D _F 5 6N. <br /> SIGNED, /j TITLE a <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE -019 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I /FINAL INSPECTION <br /> INSPECTION BY DATE IN ION BY DATE <br /> y <br /> E-H, 426 Rev.. 1-74 �:' 1177 W <br />