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fFOF .� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 OFFICE USE: 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. � Date .Issued &-S--7 <br /> (Complete In Triplicate) <br /> i 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 Local Health District. <br /> JOB ADDRESS/LOCATION <br /> r CENSUS TRACT <br />� Owner's Name Q <br /> Phone �� <br /> Address � <br /> �.� City <br /> Contractor's Name F License # � M�hone <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN/_/ RECONDITION j—/ DESTRUCTION /-7 r <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> 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 <br /> Industrial. CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private �;_ d,- .ter 71.Drilled.. -. ..- ` <br /> Domestic - Dia:.. of.�-WelI -Casing <br /> /public . Driven Gauge of-Gasing <br /> Irrigation Gravel Pack ` <br /> Depth of Grout ISeal - <br /> Cathodic Protection Rotary Type of/Grout �) <br /> Disposal Other Other �Information <br /> Geophysical Surface '5eal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. . <br /> PUMP REPLACEMENT: "4 --- — <br /> / / State Work Done <br /> PUMP REPAIR: �j <br /> State Work Done <br /> G <br />)ES•TRUCTION 'OF WELL: Well Diameter ' <br /> ` 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 mywork on a new well, I will furnish the San Joaquin Local Health District a <br />,ELL DRILLERS REPORT of the well and notify them before putting the well. in use. The above <br /> Lnformation is . ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GRO I.Nt AND A FI AL INS CTIO . <br />'IGNED <br /> TITLE ; <br /> W_PLOT PLAN ON REVERSE SIDE <br />'BASE I DEPARTMENT USE ONLY <br /> TPLICATION ACCEPTED BY zv <br /> DDDITIONAL COMMENTS: DATE <br /> PHASE Il U ION PHASE <br /> NSPECTIQN BY DATE /FIN INSPECTION <br /> INSPECTION BY DATE . 7� <br /> E H .1426 Rev. - I-74,- 077 ��r � <br />