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' SAN JOAQUIN LOCAL HEALTH DISTRICT Y <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 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 /> j JOB ADDRESS/LOCATION �1 9 CENSUS TRACT . <br /> . <br /> Owner's Name ' <br /> Phone, <br /> j <br /> AddressCity . <br /> . <br /> Contractor's Name License #2-dD Phone �4'6 <br /> 6-taG � <br /> TYPE OF'WORK (Check): NEW-WELLj2t -DEEPEN /?� RECONDITIO9� 17 DESTRUCTION /_7PUMP INSTALLATION f. PUMP REPAIR PUMP <br /> --Other-/- ` /� REPLACEMENT / f <br /> DISTANCE TO NEAREST: SEPTIC TANK :j]n . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> INTENNDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WeI1 .Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> /publicDriven Gauge of Casii►g <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout - ,A <br /> Disposal. Other Other Information } <br /> -Geophysical Surface--Seal Installed 'By:'-.-' . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. ' <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP REPAIR: <br /> /7 State Work Done ` <br /> DESTRUCTION OF WELL: 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 anew 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 TO OUTING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> f DRAW PLOT PLAN.ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � . <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSP ION PHASE MIFINAL INMCTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-r74 r -. :.irye <br />