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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ( 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V Telephoner (209) 466-6781 7S---S-Fl <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 4--7' � CENSUS TRACT <br /> Owner's Name Phone <br /> Address l City <br /> Contractor's Name w2 License #� � Phone <br /> TYPE OF WORK (Check): NEW WELL L7K DEEPEN/7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR /-7-pump REPLACEMENT <br /> Other L7' <br /> DISTANCE TO NEAREST: SEPTIC TANK > 7eR�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 OQ <br /> Industrialiilm <br /> 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 ti Rotary Type of Grout <br /> Disposal Other Other Information ~ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATIONt Contractor <br /> Type of Pump 3 H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP :REPAIR: /? State Work Done <br /> ,SES TRUCTION OF WELL: Well Diameter Approximate De <br /> FLU <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 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 GROUTING AND A FINAL I PE ION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z 7S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION / PHASE I11JFINAL INSPECTION -- <br /> INSPECTION BY 4KA!e23f DATE INSPECTION BY BATE <br /> ? E H 1426 Rev. 1-74 1-74 2M <br />