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SAN JOAQUIN LOCAL_;HEALTH DISTRICT <br /> FO$rOFF'ICE USE: 1601 E. Hazelton Ave:,':Stockton, Calif. <br /> Telephone: , (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J,S_^,o til <br /> THIS PERMIT EXPIRES 1 ,YEAR FROM :DATE ISSiFED ' Date Issued s?SY <br /> {Complete ,In -Triplicate)-r ' <br /> Applicsition is hereby .made to the San Joaquin Local Health -Disitrict for 'a permit to construct <br /> and/or install the work herein described. This Kapplication 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 /> r .• <br /> JOB ADDRESS/LOCATION �, • , CENSUS TRACT ti. r <br /> Owners Name Phone <br /> Address � <br /> 'City , <br /> I <br /> Contractor's Name License Phon <br /> TYPE OF WORK (Check): NEW WELL DEEPEN J RECONDITION /� DESTRUCTION ,%j + <br /> t <br /> PUMP -INSTALLATION / UMP REPAIR /_7_` PUMP REPLACEMENT <br /> Other J / <br /> DISTANCE TO NEAREST: =SEPTIC TANK Al SEWER LINES : PIT PRIVY <br /> ;SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> :PROPERTY LINE - PRIVATE DOMESTIC WELT%. _ ' PUBLIC DOMESTIC WELL <br /> y INTENDED USE TYPE OF WELL11 CONSTRUCTION- SPECIFICATIONS <br /> Industrial Cable Tool Dia. :of Well Excavation <br /> „_N�_�Omestic/private Drilled Dia. of Well Casing <br /> Domestic/public. Driven Gauge of Casing lort ° <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump- H.P. on <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP ',REPAIR: /7 -state State Work Done <br /> ES TRUCTION 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-beat of. myknowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION',: <br /> PRIOR TO GROUTING AND A FIN SPECTION. <br /> SIGNED TITLE <br /> REVER .�t <br /> DRAW PLOT PLAN ON SE SID <br /> :FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE .I1 ROUT INSPECTION PHASE III,FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> 4.. i <br /> E H 1,426 Rev. 1-74 <br />