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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE OFFICE USE 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .;7�_Zs 9l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> Owner's Name Phone <br /> Address up City <br /> Contractor's Name License # hone -�3 � ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INST LATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / r.... <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY q/( <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER tA <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 /> VDomestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal 57 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informat on <br /> Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .&Zv" <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 bistrict <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 OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � n DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B �JDATE <br /> 6�7 <br /> E H 1426 Rev. 1-74 / 2M <br />