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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 4`66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE, ISSUED Date Issued 7 �� <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 L I .Health District. + <br /> JOB ADDRESS/LOCATION CENSUS FRACT <br /> Owner's Name <br /> Phone <br /> Address 4 City'% <br /> - -- -- <br /> Contractor's Name / � f Licensejj/ /�� Pho 9�l <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN / / RECONDITION / J DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / J PUMP REPLACEMENT <br /> `"Other / J IA <br /> DISTANCE TO NEAREST: SEPTIC TANK _s /-SEWER LINES- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ZS-0 /CESSPOOL/SEEPAGE PIT OTHER ^✓ � " <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS ^T� <br /> Industrial Cable Tool Dia, of Well Excavation <br /> 4 4--Domestic/private Drilled Dia. ' of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal~ 1_e? <br /> Cathodic Protection Lfi�Zotary -Type of Grout � - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumps .P. 'T <br /> PUMP REPLACEMENT: / / State' Work Done <br /> PUMP .REPAIR: / J State Work Done <br /> Z. <br /> DESTRUCTION OF WELL: Well Diameter <br /> ti <br /> ,Approximate Depth <br /> Describe Material and ,Pr.ocedure„_ii�,,_Q <br /> I hereby agree to comply with all laws and regulations"bf 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 well in use.. . The above <br /> information is -'trud',to -the best of my knowledge and ,b°elief. �I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TI AND 'A FINAL INSPEC N. , <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II C UT INSPECTION .•ma 'ry PHASE III/FINAL-INSPECTION• <br /> INSPECTION BY DATE INSPECTION BY f DATff;i <br /> /' <br /> EH1426 Rev. -74 /7 2A <br />