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SAN JOAQUIN LOCAL'HEALTH DISTRICT - <br /> FO—R OFFICE USE: Z1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: '(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]� <br /> THI$,PERMIT +EXPiRES 1 YEAR FROM DATE :ISSUED Date Issued7� <br /> :(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> and/or install the work herein described., This application is made_in,compliance with San Joaquin <br /> County Ordinaiace No. .1862 ,and the- Rules, and Regu3ations-of .the San Joaquin Local Health'Disntrict. <br /> JOB ADD$LSS,/LOCATIONs' , /�,�yl. /�Cf'/ � iL,A&1V CENSUS :TRACT <br /> Owner's Name gr" � / � Phone <br /> Address " City (" ' .;. <br /> Contractor'a Name 4j c License Phone <br /> TYPE OF WORK, (Check): _NEW WELL /4?---DEEPEN' /. / RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> trial 4---;-Table Tool Dia. of Well Excavation <br /> �_ Domestic/private Drilled Dia. of Well Casing _ _ <br /> Domestic/public : Driven Gauge of Casing f <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' s ( <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By• <br /> PUMP INSTALLATION: ` Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP :REPAIR: 17 State Work-Done <br /> ,REES RUCTION 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 "WILE CALL FOR A GROUT INSPECTION <br /> PRIOR TO GOTIK AND A FINAL IHMCTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE BIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA' �II��G��� ROUT INSPECTIONPHAS I INAL INSPECTION <br /> INSPECTION BY-e% l1! DATE INSPECTION BY DATE 6 <br /> l E H 1426 Rev. 1-74 1-74 2M <br />