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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> : FOR.MFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> F Application is hereby trade 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 31 City <br /> k <br /> 'L Contractor's Name License # Phone��a:auz <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN -/-7 RECONDITION /,X DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO DEAREST: SEPTIC TANKSEWER-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' Drivers Gauge of Casing (r <br /> t Irrigation Gravel. Pack Depth of Grout Seal <br /> E Cathodic Protection Rotary ,, Type of Grout J�- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION. Contractor <br /> ( Type of Pump ri ��� H.P. <br /> } <br /> PUMP REPLACEMENT: ' - <br /> State WarkDone,..,,_. <br /> PUMP ,REPAIR: / / . State Work Done H _. <br /> PES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Prosedue- " - <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 toi�the.best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR <br /> 94TING AND AiTINAL INSPECTION. <br /> SIGNED " TITLE <br /> .I (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I\ u <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 11 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 7, DATE zf'' <br /> } E H 1426 Rev. 1-74 1-74 2M.. <br />