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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> F9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedf <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 /> Owner's Name zz Phone <br /> Address City <br /> Contractor's Name A.M. r, C�1��Cnf ik License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_7 " <br /> PUMP INSTALLATION / / PUMP REPAIR/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK fLL� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL VA PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS An <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �j Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grouta. <br /> 50 <br /> Disposal Other - ^� 2-nrr�' <br /> Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.` -- - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter " Approximate Depth Fe <br /> Describe Material and Procedure -- <br /> 1 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 thewell 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 GROUTIN AND A FINAL INS ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR D PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE j <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> E H 1426 Rev. 1-74 if/7 2M <br />