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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-,_ FFXCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I, YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son Joaquin Local Eiealth District for a permit to construct <br /> i 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 Al 'w- <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> i Address <br /> r 1 City ' h <br /> Contractor's Name n Lf..c,u License # I-ft phone 6 <br /> 79 <br /> TYPE OF WORK (Check): NEW WELL,-L7 DEEPEN -17 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION ,/—/ PUMP REPAIR'LX� PUMP REPLACEMENT f7 <br /> Other <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 /> - INTEND-ED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> indusdustrrial Cable Tool Dia, of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - Irrigation Gravel Pack Depth of Grout Seal <br /> CathodicProtection Rotary Type of Grout <br /> ---.-Disposal Other Other- Information- <br /> -Geophysical - - Surface Seal Installed B i <br /> i <br /> PUMP- INSTALI.ATIONe Contractor vim} <br /> Type'.of Pump H.P. <br /> PUMP 'REPLACEMENT.— - <br /> / / State Work Done <br /> PUMP '.REPAIR: <br /> ,1�.!/ State Work Done <br /> ji <br /> OES.TRUCTION OF WELL: Well Diameter <br /> . . Describe Material and Procedure Approximate Depth <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 /> F <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 %FOR <br /> dge belief. I WILL CALL 'FOR 'A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSIGNED <br /> OT PLAN ON RE E SIDE) <br /> PHASE I <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE 11 GROUT INSPECTION: PHASE III FINAL -INSPECTIQN <br /> INSPECTION BY DATE ` <br /> INSPECTION BY DATE <br /> E H 1426 Rev. 1"74 <br />