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f v <br /> _ SAN JOAQUIN�•LOCAL HEALTH DISTRICT <br /> IOFFICE USE, ` <br /> E F08 1601 E, Haxelton:Ave. ,:..Stockton, Calif. <br /> Telephone:. ,. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NdfL R '"``1f1 <br /> THIS PERMIT EXPIRES -1 ;YEAR..FROM DATE ISSUED Date Issued 14- <br /> (Complete In Triplicate) <br /> Ili Application is"he'raby made to the San Joaquin-Local. 1Iealth Diattict 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 CENSUS TRACT <br /> Owners Name Phone <br /> Address <br /> City <br /> Contractor's NameC`1. License Phone <br /> .TYPE OF WORK (Check): NEW WELL / DEEPEN /_7 RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / J PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other 1 I <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 <br /> TYPE OF <br /> WELL <br /> CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation 0' a <br /> ' Domestic/private DrilledDia. of Well Casing <br /> Domestic/public Driven Gauge of Casing . 1 le <br /> 'Irrigation Gravel 'Pack Depth of Grout Seal .14 ,4 _.i. <br /> Cathodic Protection �G Rotarq ' Type of Grout <br /> Disposal Other Other Information �W <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of PUMP H.P. <br /> r <br /> PUMP REPLACEMENT: %/ State Work Done <br /> I� PUMP '.REPAIR: . . , . ,..._ ,. ,.. ...,.... <br /> L7 State Work Done. __ . -. _ <br /> ES TRUCTION OF WELL: Well Diameter 4 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 a new well., I will` furhish the San Joaquin Local Health District_ a <br /> WELL DRILLERS REPORT of the well and notify them before putting. thewell 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 GROVOING MA FIN INSP CTION. <br /> SIGNED `"� TITLE <br /> (DRAW PLOT- PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I G <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: T <br /> PHASE II OUT INSPECTION -. PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE � INSPECTION BY DATE <br /> 'i E H 1426 Rev. 1-74 1-74 2M <br />