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�6 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFOE- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �]� �73,� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <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 j <br /> County Ordinance No. 1862 and the. Rules and Regulations of th an Joaquin Local Health- District. <br /> I. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> LQ License � ���� �Phone I <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 �. <br /> PUMP INSTALLATION / PUMP REPAIR I / PUMP. REPLACEMENT /_7 <br /> Other <br /> DISTANCE CO 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 /> Y 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 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other yp f <br /> Other Information � <br /> Geophysical Surface Seal Installed B : <br />'UMP INSTALLATION: Contractor - \ <br /> Type of Pump <br /> H.P. <br />'UMP REPLACEMENT: / / State Work Done <br />`UMP •.REPAIR: / / State-Work Done �I <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and, Procedure <br /> hereby agree to comply with all laws am regulations of' the Sari Joaquin Local Health District <br /> nd the State of California pertaining to�or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well;I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1IOR TO G UTING FIN INSPE ION•.4:;. <br /> IGNED TITLE <br /> p!c <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PHA IT IN INSPECTIO <br /> VSPECTION By DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 . , 11Z7 2M <br />