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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209)466-6781 I <br /> P 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 ,Z f' CENSUS TRACT <br /> Owner's Name j' _ Phone <br /> Address City <br /> Contractor's Name &4ZZ ZZ&ALicense gZ& 4-Vhone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/_/ DEEPEN /3 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> rhe+ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <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 4V •y <br /> Industrial.. _ . ..v Cable-Tool-. , Dia. of Well Excavation v <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 k Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> f <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - / / State Work Done E <br /> PUMP .REPAIR: � ... / / State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 4 <br /> f Describe Material and Procedure <br /> ; <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, th6 well -and notify them before putting the- well in use.. The above <br /> information isitrue to the best}'of""mi knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO ;GROUTINGA FTN SPE CT ION. �. <br /> SIGNED t TITLE <br /> (DRAW PLOT !PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � - <br /> APPLICATION ACCEP BYDATE 5` /t <br /> ADDITIONAL •COMMENTS. a <br /> PHASE I I' GROUT'_INSPECTION - __P S• -I - •/Fl - NSPECTION.. <br /> INSPECTION BY DATE _ INSPECTION_BY DATE -.��}-+� <br /> �t <br /> E H 1426 Rev. 1-74 ' 1177 2N . <br />