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SAN 'JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR�OFrICEE USE: 1601 E., Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� '� .ul <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 NamePhone 3�e <br /> Address I Cityecza�!" <br /> Contractor's Name w � L � ense Phone 7 <br /> TYPE OF WORK (Check): NEW WELL /;T'DEEPEN /7 RECONDITION /-7 DESTRUCTION �]' <br /> PUMP INSTALLATION /7 PUMP REPAIR /_7 PUMP REPLACEMENT ZZ, <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1.0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE D-TMSTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a le Tool Dia. of Well Excavation 1� <br /> �mestic/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 <br /> Geophysical Surface Seal Installed By: Q <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /Z� State Work Done W <br /> PUMP :REPAIR: -7 State Work Done <br /> ,SES TRUCTION 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 puttingthe..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 GROUTING D FINAL NSPE ION. <br /> SIGNED: <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE-ONLY <br /> PHASE 'I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION' PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY - DATE /a 1/W <br /> E H 1426 Rev. 1-74 1-74 ZM <br />