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'SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> r FO&:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i <br /> Telephone: (209) .466-6781,. <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X26 <br /> (Complete In Triplicate) <br /> Applicdtion is hereby made to the Scan Joaquin Local stealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LO ION CENSUS TRACT <br /> Owner's Name Phone <br /> 3. Address ��- <br /> Cit <br /> Contractor's Dame <br /> License 4hon1P~" <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN '/7 RECONDITION /— DESTRUCTION /-J <br /> PUMP INSTALLATION j / 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 0 <br /> ______•Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel, Pack- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout e <br /> Disposal - Other ��� Other Information <br /> Geophysical - - - t Surface Seal. Installed 'B <br /> ; <br /> PUMP INSTALLATION: l Contractor x <br /> Type .of Pump <br /> - ii.P. ' <br /> PUMP REPLACEMENT: State Work Done <br /> State;Work D <br /> DESTRUCTION OF WELL: Well Diameter <br /> . Approximat epth�-�� <br /> Describe Material and Procedure <br /> i <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..well in-use... The above <br /> t 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 /> (DRAW PLOLAN ON REVERSE SIDE <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE , <br /> PHASE TI GROUT INSPECTION P AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-71� <br /> i - - <br />