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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS,,- -FTCEAUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 94 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 24-7f_ <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 Jo4quin i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. {� <br /> JOB ADDRESS/LOCATION L. CENSUS TRACT <br /> Owners Name <br /> Phone <br /> Address City <br /> Contractor's Name License # Phone <br /> X <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/_/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ..1 <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 <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 Protection Rotary Type of Grout �r <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <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 <br /> pproximate Depth <br /> �.... Describe Materifdl 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 G UTING AND FINAL INSPECTION. <br /> SIGNED TITLE !A f <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a 7 g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION V PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY--_ DATE 7— <br /> ry /�� <br /> E H 1426 Rev. 1-74 <br />