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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FbEQFFICE USE: '` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> • I <br /> THIS PERMIT EXPIRE$ 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. 1862 and the Rules a d Regulations of the San Joaquin Local Health District. <br /> �y .f <br /> JOB ADDRESS/LOCAZ , .. `�` CENSUS TRACT <br /> E <br /> Owner's Name --^ Phone <br /> Address �a ' Cit <br /> Contractor's Name 4z/ License Phone <br /> TYPE OF.,WORK__(Check) : _NEW WELL I I�_DEEPS RECONDITION /_� -DESTRUCT <br /> N/ / PUION / <br /> PUMP INSTALLATIOMP 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 rn <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 r <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor _J <br /> Type of=-Pump, H.P. <br /> S <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / /—State Work Done <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 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 true to the best of my.knowledge and belief. I. WILL FOR A GROUT INSPECTION <br /> PRIOR TO GARUTING A FINAL INSPECTION: <br /> SIGNED .ZZJ TITLE <br /> :,�(DkAkAbT PLAN' ON RE ELSE S IpE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION "ACCEPTED BY ,,�, . .. _ _ _,.DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION„-' PHASEI I INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BYt/ ATE//-" -0 <br /> q <br /> E H 1426 376 2M <br /> Rev. 1=74 <br />