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SAN JO,1QUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE SSE:- <br /> 1601'r <br /> -ill Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 6 I�} <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/LOCATION CENSUS TRACT <br /> Owners Name f Phone <br /> City <br /> Address E �b - <br /> Contractor's Name 6 License #,=ar <br /> Phone � _ze <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_ / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION / / UMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES PIT PRIVY <br /> SEWAGE DISP08A-L FIELD Z64/ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVA E DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 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 Other Information <br /> Geophysical Surface Seal Installed By : C <br /> 1r <br /> PUMP INSTALLATION: Contractor o <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done a <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 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 best of my knowledge and belief. I WILL L FOR A UT IN TION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT LAN ON---R- ERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY i DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION HAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE fp y2-?7 <br /> 2M <br /> iI 1426 Rev- 1-74 <br />