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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'OFFICE 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 /p-a-7 <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 Jo in Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's, Name - �`� License # Phone U <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN '17 RECONDITION /7 DESTRUCTION /—jl.. <br /> PUMP INSTALLATION E/ PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other E7 <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 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 <br /> Disposal Other Other Information <br /> Geophysical. 'Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump #I.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPtREPAIR: / 7 State Work Done <br /> &ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> . . Describe Material and Procedure i <br /> i <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 CAW FORA GROUT INSPECTION <br /> PRIOR TO GROUTING Hp INAL INS PE N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:_ <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ��� �• ;� <br /> INSPECTION BY . MM DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 I-74 2M <br />