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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �� ` �Ol <br /> to <br /> FO&,OFFICE USE; 1,601 E. Hazelton Ave. , Stockton, Calif. �� '' A - C27 6) <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR-PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSU A <br /> (Complete Date Issued <br /> i Application is hereby made to the SanJoa <br /> uina <br /> LolrHealth District for a permit <br /> t <br /> and/or instali the work herein described. This application Is made in compliance withnSan uJoaquin <br />� FCounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br />' Phone ` <br /> Address 7 <br /> Cit <br /> Contractor's Name <br /> License # _ Phone - f j <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN ' <br /> /_7 RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR /? PUMP REPLACEMENT /-7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> -< SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT f <br /> PROPERTY LINE PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> DomestiCable fool Dia. of Well Excavation <br /> c/private Drilled Dia. of Well Casing <br /> Domestic/public � � Driven <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal t <br /> Cathodic Protection -.___� Rotary Type of Grout - <br /> Other <br /> rout t <br /> Disposal ��� OtherOther Information' - <br /> Geophysical Surface Seal Installed 'B <br /> _ <br />,PUMP INS TALLATIONa Contractor �a <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT Ll State Work Done , <br /> e , C Awl <br /> PUMP 'REPAIR: �1 / <br /> State Work Done 4e f�11. <br /> DESTRUCTION OF WELL: , Well Diameter <br /> IS 1300 AFF oxim to Depth <br /> Describe Material an 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 '4 <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 -FORA GROUT INSPECTION <br />'RIOR TO GRO I G-AND A VT,.,,, INSPECTION. <br />>IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br />►PPLICATION' ACCEPTED BY I <br /> r <br /> IDDITIONAL C0101ENTS: , , DATE <br /> PHASE II GR UT INSPECTION ,... <br /> INSPECTION BY PHASE III INAL INSPECTION <br /> DATE INSPECTION BY DATE <br /> E H 1426Rev. 177 4 <br /> (, <br />