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SAN JOAQUIN LOCAL HEALTH DISTRICT f , <br /> FORiOFFIC,E USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> . <br /> Telephone: (209) 466-6781 <br /> 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/LOCATI6N _ CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address r City <br /> Contractor's Name License # yL402- Phone 5/G2-- SST <br /> TYPE OF WORK, (Check): :.NEW WELL - DEEPEN - - <br /> .� /_� RECONDITION /_� DESTRUCTION /']' <br /> INSTALLATION /� PUMP REPAIR /? PUMP REPLACEMENT -7 <br /> ` s Other <br /> f <br /> DISTANCE TO NEAREST; SEPTIC TANK —SEWER LINES PIT PRIVY i <br /> SEWAGE DISPO AI. FIELD _ CESSPOOL/SEEPAGE PIT OTHER � I <br /> PROPERTY 11k - PRIVATE DOMESTIC WELL' - PUBLIC DOMESTIC WELL <br /> INTENDED USE M TYPE'OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f q� <br /> � Cable Tool Dia. -of Well Excavation p_ <br /> Domestic/private I Drilled Dia: of Well Casing <br /> Domestic/public Driven Gauge of Casing IQ <br /> 1, f Irrigation Gravel Pack Depth of Grout Seal G <br /> 1 Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Geophysical Other Other Information <br /> '"�` "'�""�` •i <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor '_ <br /> F <br /> ; Type of Pump S.P. , <br /> kUMp REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: - / .7 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 wil11 furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT f the well and notify them before Putting—the—well in.use.. The above <br /> informatio r t `` the) : st of my.knowledge and belief. I' WILL CALL FORA"GROUT INSPECTION <br /> PRIOR TO G U D A FI ECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> 3 FOR DEPARTMENT USE ONLY <br />_PHASE I_ , <br /> APPLICATION ACCEPTED BY ! DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE <br /> I GILOUT INSPECTI PHAU IIIJgINAL INSPECTI <br /> INSPECTION BY DATE Z INSPECTION BY DATE / 7@ <br /> E �H 1426 Rev. 1-74 <br /> 1-74 2M <br />