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r 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. .26-/!E-gfn <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sun 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 <br /> /Jthe <br /> ((�}Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone,16 <br /> Address 1 City <br /> Contractor's Name LicensePhone <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN ,/7 RECONDITION /-7 DESTRUCTION 17 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other /-7 <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 0 <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 Protect_ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. /S <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,REPAIR: o. State Work Done do <br /> i5 <br /> DESTRUCTION OF WELL: Well Diameter _ L 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 ue to the•b t of my owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU 4D A INSPE N. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY c DATE 11 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IJI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE 3 <br /> E H 1426 Rev: 1-74 h/75 2M- <br />