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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, ' Calif. tiS <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 <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 /> JOB ADDRESS/LOCATIWi <br /> � � � '�. o VY-v ev cENsus- TRACT <br /> Owner's Name Phone <br /> Address �. - - - <br /> CitY 6F 07-zle,rJ <br /> Contractor's Name I/At r /?S a 1 License Phone <br /> V <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN-/_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR /L�_PUMP REPLACEMENT / / <br /> Other <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS �} <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing : <br /> e--- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout f <br /> Disposal Other Other Information <br /> Geophysical Surface. Seal Installed By : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP .REPAIR: t /tom State Work Done u,s,�q/ �4 <br /> Y <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 a new well, I will furnish the' San Joaquin'Local Health District ael <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe. we11 in use The above F <br /> information is true to the best of my knowledge and belief. 'I WILL CALLFOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE " y.�c <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .:DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE.II GROUT INSPECTION PHASE FINAL -INSPECTION # <br /> INSPECTION BY DATE r INSPECTION B AT <br /> E H 1426 Rev. - 1-74 2M 0 <br />