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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <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 Regulatio,�}s of the San u n Local Health District. <br /> JOB ADDRESS/LOCATION f i G CENSUS TRACT <br /> Owner's Name Vev Phone <br /> Address City <br /> kt —ri <br /> Contractox's Name ',/ �,+ i A d LD4License ��� 4 Phonej' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <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 /> Ind-ustrial � le Tool Dia. of Well Excavation <br /> �mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing T r <br /> �rigation Gravel Pack Depth of Grout Seal k <br /> Cathodic Protection Rotary Type of Grout <br /> 6. <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: / / State Work Done <br /> DESTRUCTION 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 DAIS <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 be of my knowledge and belief. I WILL CA4L FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG AND FIN SP CTION. <br /> SIGNED - TITLE " + <br /> ( PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IQ <br /> APPLICATION ACCEPTED BYI_�J ,J DATE -� <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 1 <br />