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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USn 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> NIV 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/LOCATION. ��-n CENSUS TRACT. , <br /> Owner's Name Phone <br /> Address _ a �� <br /> City l r <br /> Contractor's Name License # ! `Phone - <br /> _2" <br /> i <br /> . TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /' / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY [�! <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE W PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL __ M <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of'Grout Seal O <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal OtherOther Information _ <br /> Geophysical Surface Seal Installed.By: <br /> : <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump t4JAI H.P. / <br /> PUMP REPLACEMENT: / State Work Done' —n-'slc// <br /> PUMP REPAIR: / / State Work Done <br /> 1# <br /> DESTRUCTION OF.WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> a <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 my know/lex1givnd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INVE T <br /> SIGNEDoGc IT r <br /> r (DRAW 13LOT PLAN ON -VVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSVIIZZ <br /> INSPECTION BY DATE INSPECTION BY DA <br /> 0/77 - 2M <br /> k E H 1426 Rev. - I-74 <br />