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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 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 <br /> Date Issued -�j.,.� <br /> (Complete In Triplicate) <br /> f 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 '7 <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> f Address ��a /' .- �j Q <br /> City <br /> Contractor's Name <br /> License # &.1 1_ Phone 7 <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN " _ � E i <br /> / / RECONDITION /_% 'DESTRUCTION /_7PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRI <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel 1 Excavation <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 .Gr'out <br /> Disposal. -•-�- _ .� � _. �� Other r A.•. _ t <br /> Geophysical Other Information <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump' <br /> H.P. <br /> PUMP REPLACEMENT /__7 State Work Done <br /> PUMP ` : r <br /> / State Work Dane �r ,�� d <br /> DES.'TRUCTION OF WELL: Well Diameter` <br /> Describe Material and.Pracedure Approxi ate 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'wel1, '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 GROUTI G AND A FINAL INSPECTI <br /> SIGNED ITLE ` <br /> D :P : T P 'ON RE RS SIDE) <br /> 71 <br /> PHASE I R DEPARTMENT USE ONLY. <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II OUT SPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE <br /> x <br /> r <br /> E H 1426 Rev. .1-74 . y 376 2Ni <br />