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(V / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 'OF.FICE.,USE: f/ 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 Date Issued &,-,/ 6 <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 Regulation of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Na <br /> Phone <br /> Address s` �' <br /> City <br /> Contractor's NameL-� License 44�) 37 Phone �� � <br /> TYPE OF WORK (Check) ; NEW WELL _/_7 DEEPEN / / RECONDITION /�/ ^DESTRUCTION /_7 <br /> PUMP INSTALLATION ' PUMP REPAIR/ / PUMP REPLACEMENT /7 <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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information f <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of P H.P. <br /> PUMP REPLACEMENT: 117 State Work Done <br /> PUMP-REPAIR: <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 ray worm on a new well, I will furnish the San, Joaquin Local Health District a F <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 GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> D W <br /> 1tft PLAN 'ON RKWkSE SID ° <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMSNTS: <br /> PHASE II G UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /�- DATE <br /> E H 1426 Rev. 174 , 3/76 214. . <br />