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SAN JOAQUIN LOCAL HEALTH DISTRICT h <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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/LOCAN CENSUS TRACT <br /> Owner's Name Phone <br /> Address i City <br /> Contract'or's Name License ��� hone ' <br /> - i <br /> TYPE-@F--WORK (Check) : NEW WELL / DEEPEN / J RECONDITION /� DESTRUCTION f? <br /> PUMP INSTDATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE -T-0 NEAREST: SEPTIC TANSEWER LINES PIT PRIVY <br /> SEWAGE DISP FIELD C OL/SEEPAGE PIT OTHER <br /> f ' 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 /> ,--5omestic/private Drilled Dia. of Well Casing , 17/ <br /> _ _ •_ � <br /> Domestic/public Driven Gauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout Q <br /> Disposal ' Other .; � Other Information _ � <br /> Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ' ea <br /> Type of Pump <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 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 f my knowledge and belief. I WILL CAL FORA GROUT INSPECTION <br /> PRIOR TO GRO G AN FIN SPE CTXON. <br /> SIGNED - TITLE <br /> W P PLAN 'ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -2 y_ 2Z _ <br /> ADDITIONAL .COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III./FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> DATE <br /> • E H 1426 Rev. 1-74 <br /> 3/76 2M <br />