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/ SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> YORIOFFICE 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 J <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> r <br /> Owner's Name Phone <br /> AddressZ 61C d' Cit <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN -/-7 RECONDITION /_7 DESTRUCTION 17 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other f_1 <br /> i <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 i <br /> INTENDED USE TYPE OF WELL CANSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing.. - A <br /> Irrigation Gravel Pack Depth of Grout Seal �1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information . <br /> Geophysical Surface Seal Installed-BX:- <br /> PUMP <br /> nstalledB :PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> f <br /> PUMP ,.REPAIR: State Work Done I <br /> ES-TRUCTION 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 puttingthe. wel.l 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 SOUTING AND A NAL IN PECTION. <br /> SIGNED TITLE per , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY : C� DATE <br /> ADDITIONAL COMMENTS: `� 16 7,r <br /> PHASE II OUT INSPECTION PHASE TTI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1-2- <br /> t E H 1426 Rev. 1-74 1-74 2M <br />