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f <br /> i, <br /> 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. 7� <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 /> County Ordinance No. 1862 and the Rules and Regulations oand/or install the work herein described. This application is made in compliance with San Joaquin <br /> f th San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA ON CENSUS TRACT <br /> Owner's Name .� Phone <br /> Address City! ���� <br /> Contractor's Name � „c� .�'�� License #�&ePhone <br /> TYPE OF WORK (Check): NEW WELLL7 DEEPEN/7 RECONDITION /? DESTRUCTION / f <br /> PUMP INSTALLATION /� PUMP REPAIR /_J PUMP REPLACEMENT <br /> Other /_7 <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 /> Industrial 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 Rotary Type of Grout <br /> Disposal Other Other Information ` <br /> Geophysical - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracto Y c' <br /> Type of Pump <br /> B.P. / <br /> PUMP REPLACEMENT: /f State Work Don <br /> PUMP :REPAIR: /? State Work Done <br /> ,RES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 o the best of my knowledge and belief. I WILL L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN D FI I SP ION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATEE H 1426 Rev.qqd:Z:�� <br /> 1-74 <br /> 1-74 2M <br />