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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE•USE`:* 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued v2 <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 , u�al_ ns o,� the an Joaquin Local Health Districtl <br /> JOB ADDRESS/LOCATION . - , NSUS TRACT <br /> Owner's Name � hone <br /> Address City _J <br /> Contractor's Name License # 2q6.&3Phone =/�1 - <br /> r <br /> TYPE OF WORK (Check) : NEW WELL aK DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �. <br /> SEWAGE DISPOSAL FIELD /6t2L* CESSPOOL/SEEPAGE PIT OTHER OKI <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL pC <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing fJ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ,� T <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A IN INSPECTION, <br /> SIGNEDTITLE �r�. <br /> (DRAti LOT PLAN ON PERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III UNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY < DATE <br /> r <br /> 2M <br /> E H 1426 Rev. - I-74 0�%7 <br />