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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE. l�1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone; (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Isp4ed <br /> (Complete In Triplicate) <br /> Application is Aereby 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. 1$62 and the Rules and Regulations of. the Saxe Joaquin Local Heaith District. <br /> JOB ADDRESS/LOCATIQN CENSUS TRACT <br /> Owner's Name Phone <br /> Address 2 Q. !/ City <br /> Contractor's Name QQ Q i <br /> �.J oLicense #V'yw`hong <br /> TYPE OF WORK (Check) :. NEW WELL/ / DEEPEN /7 RECONDITION /? DESTRUCTION / ¢ <br /> - PUMP INSTALLATION Z4 PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHNR <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 Q <br /> 'Domestic/private Drilled Dia. of Well Casing Q <br /> , .Domestic%public Driven Gauge of Casing <br /> Irrigation Graver Pack Depth of Grout Seal 4E <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: ; <br /> PUMP INSTALLATION: Contractor <br /> a <br /> Type of Pump H6"P. <br /> _ € <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 Healthistriot. <br /> a <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 tXue to tho best of my knowledge and belief. I WILL CALL FORA GROAT INSPECTION <br /> PRIOR TO PXQUTING AND A FINAL'_INSPECTION.. <br /> SIGNED, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> E . <br /> APPLICATION ACCEPTED BY DATE 2:2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, III FINAL TN_$PZCTjbN j <br /> INSPECTION BY DATE INSPECTION BY - DATE .7 <br /> E H 1426 Rev. 1-74 1�r 2M 1 <br />