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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0fi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. _ 7p <br /> Telephone: (209) 466-6781 <br /> 45 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 /> Owner's Name Phone, ( � <br /> Address �E City <br /> Contractor's Name w„� License y honedBQ <br /> /01 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /7 UMP RE AIR /_7 PUMP REPLACEMENT /7 <br /> Other /� <br /> DISTANCE TO NEAREST: SEPTIC TANK S INES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD S., E PIT OTHER <br /> PROPERTY LINE - PRIVA 4aWELL PUBLIC DOMES IC WELL <br /> INTENDED USE TYPO OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable 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 4Llz� <br /> Geophysical Surface Seal Installed By: <br /> "-Z <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP .REPAIR: L State Work Done <br /> pESTRUCTION 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 R GROUT INSPECTION <br /> PRIOR TO ROUT G to A ZINAL INSPIJCTION, , <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 RROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ° DATE INSPECTION BY ity, DATE - <br /> E H 1426 Rev. 1-74 1-74 2M <br />