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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO . OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> e 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. 186-2 and the Fu,les aj2d Reg ations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ► CENSUS TRACT <br /> { <br /> Owner's Namee�z('? Q�z2 Phone <br /> �/Address City ' <br /> Contractor's Name �_ .. 4 <br /> / *�. - �/� License �� r�/Phone-- <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 f <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> e r <br /> 'Other <br /> DISTANCE TO_ NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> A. PROPERTY LINE = PRIVATE DOMEST.IC.WELL PUBLIC-DOMESTIC. WELL j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia, of Well Excavation \1I <br /> Domestic/private `Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Dep`th�,of Grout Seal <br /> Cathodic Protection, . Rotary Type,of Grout I <br /> Disposal `+ Other Other Information <br /> Geophysical -. Surface Seal Installed By: <br /> S s <br /> PUMP INSTALLATION: Contractor <br /> Type of.Pumpr. H.P. <br /> ' j <br /> PUMP REPLACEMENT: State Work Done F (,G <br /> _ I <br /> PUMP -.REPAIR: / / State Work Done <br /> DE&TRUCTION OF WELL": W 11 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 a <br /> WELL DRILLERS REPORT of the-well and notify them before putting the wellin 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 FINAI,3 INSPE TION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE x <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IttPECTION PHAS ILEI/FINAL INSPEC IO <br /> INSPECTION BY DATE INSPECTION BY U DATE <br /> 1f17 <br /> E H 1426 Rev. 1-74 <br />