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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. • <br /> f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t <br /> THIS PERMIT' EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> k Application is hereby made do 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 Joaqui <br /> County Ordinance•'No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,j /f - f' CENSUS TRACT <br /> Owner's Name Phone <br /> Address " <br /> City 451 <br /> Contractor's Nacre �. //� <br /> License Phone3' S <br /> TYPE of WORK (check) : NEW WELL '/-T DEEPEN/;RECONDITION /7 DESTRUCTION /'7 <br /> PUMP INSTALLATION / / PUMP REPAIR /? PUMP REPLACEMENT /7 <br /> Other r7 . . . . <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 able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ., <br /> Irrigation Gravel Pack m Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other- Information <br /> Geophysical Surface Seal Installed B <br /> fk <br /> ' PUMP INSTALLATION: Contiactor <br /> _- Type of Pump H.P. <br /> PUMP REPLACEMENT: . /State Work Done <br /> ' Pt3I� 12EPAIR: / J"';tate Work Done - <br /> DESTRUCTION OF WELL: WellDiameterApproximate 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 t-o 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 /> r <br /> infomation is true to the•best-of my.knowledge and belief. I WILL CALL -FOR A GROUT INSPECTION <br /> PRIOR TO GRWIN9 ANDLA FINAL IKSPECTION. <br /> SIGNED --u TI TLE _ <br /> (DRAW PLOT PLAN ON' REVERSE SIOE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � ,�, <br /> APPLICATION ACCEPTED BY DATE 3' <br /> ADDITIONAL COMMENTS: <br /> # PHASE lI GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE 2d <br /> E H 1426 Rev. 1-74 µ f 1�l�K 9M <br />