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SAN JOAQUIN LOCAL HEALTH DISTRICT k <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 is3ere by 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 f'C7 CENSUS TRACT <br /> Owner's NamePhone <br /> Address S.me*f City <br /> Contractor's Name "/� s � sI License <br /> ePhon,3 <br /> TYPE OF WORK (Check) : NEW WELL / E --DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /s--r'PUMP REPAIR _/ J PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK jer SEWER LINES PIT PRIVY <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing _ 7 <br /> Irrigation Gravel Pack Depth of Grout Seal _4-0 <br /> Cathodic Protection otary Type of Grout czl_)V ,,.> <br /> Disposal Other Other Information �� <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor LI JP <br /> Type of Pum H.P. <br /> YP P _ �.._._._. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth \ <br /> Describe Material and Procedure R <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 GROU ING AND A FINAL INSPEC` N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY SATE <br /> 117 <br /> . b/77 2M <br /> E H 1426 Rev. , 1-74 <br />