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i <br /> BAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 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 ] 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 constfuct <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. j CENSUS TRACT s <br /> ■ `4 <br /> Owner's Name ,. J � ��� <br /> S' / Phone <br /> Address _�. _ city <br /> Contractors NameLicense ��� Q/D Phone <br /> TYPE OF WORK (Check) : NEW WELL / / , DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT- <br /> Other <br /> EPLACEMENT0ther / / <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 TELL CONSTRUCTION SPECIFICATIONS <br /> . Industrial4 , ' 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 By: <br /> PUMP INSTALLATION: � - Contractor <br /> Type' of.'Pump H.P. . <br /> Vr ' <br /> PUMP REPLACEMENT: ` ^ . State-Work Done s <br /> PUMP REPAIR:' ', : / / State Work Done <br /> DESTRUCTION 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 Distract <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 r <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in usiRt-.'The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR' A GROUT INSPECTION <br /> PRIOR TO GROUT G AND A 9INAL NSPEC N. <br /> SIGNED - TITLE <br /> zz (DRAW PLOT PLAN ON REVERSE SIDE) .: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY49 <br /> 10 DATE <br /> 4 <br /> ADDITIONAL COMMENTS: <br /> PHASE I OUT INSPECTION � PHASE III/FINAL INSPECTIO <br /> INSPECTION BY 110--- DATE INSPECTION BY DATE <br /> E H 1426 Rev. , 1-74 0.77 2M <br />