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SAN JOAQUIN LOCAL HEALTH DISTRICT 0 <br /> FOF OFFICE USE: 3601 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/a <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to const <br /> ruct <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 /> CENSUS TRACT <br /> Owner's Name <br /> Phone , <br /> Address 7 <br /> city . <br /> Contractor's Name License #,;t$S� Phone JL, � J <br /> — <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION / / DESTRUCTION /_ ' <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT f // <br /> Other — <br /> DISTANCE TO NEAREST: SEPTIC TANK _Ial� SEWER LINES PIT PRIVY _ 1 <br /> SEWAGE DISPOSAL FIELD <br /> 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 -V <br /> Domestic/private Dia., of Well Casing (� <br /> --�-- Drilled <br /> Domestic/public Driven x "Gauge of Casing - <br /> Driven <br /> Irrigation Gravel Pack `Depth.,of' Grout Seal <br /> Cathodic ProtectionRotary �IYPe of G <br /> f <br /> ` Disposal �v Other <br /> rout <br /> Other Information <br /> —Geophysical, Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' 4 <br /> Type of Pump <br /> - _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done : <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 new 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 r <br /> PRIOR TO GROUTING AN FINAL INSPECT <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHA-SE--I FOR DEPARTMENT USE ONLY <br /> APP-LIGATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. • 1--7.4 2M ' t <br />