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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: VPLICATION <br /> 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedo <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 an 'Joaquin Local Health District. <br /> JOB ADDRESS/ ION CENSUS TRACT <br /> Owner's N Ph / 7- <br /> A7;r <br /> ddress p/��C.• <br /> b / <br /> Contractor's Name License ig�;???9?hone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/? RECONDITION j DESTRUCTION /7PUMP INSTALLATION /� PUMP REPAIR,/-7—PUMP REPLACEMENT <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ,PROPERTY LINE - PRIMATE DOMESTIC WELL' PUBLIC DOKEShC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Gable 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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /r State Work D ` <br /> PUMP ,REPAIR: /7 State Work Done �� -44 <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BY .. s.',c. DATA <br /> ADDITIONAL COMMENTS <br /> PHASE II INSPECTION EWE OWFINALf INSPECTION <br /> INSPECTION BY INSPECTION BYIV <br /> E H 1426 Rev. 1-74 <br />