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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE--OFFICE USE: �/'�1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �e�Klw <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 Regulations/o the San Joaquin Local Health District. <br /> JOB ADDRESS/LOC TION 1�f-)- CENSUS TRACT <br /> Owner's NamePhone <br /> Address y :f ►� t �r �- �` - City � - <br /> ' ✓��° .,. License # a Phone <br /> Contractor s Name , --�J i dry s <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITION /_/ DESTRUCTION / <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 /> 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: Contractor ✓ <br /> rr( r <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 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 FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND A FINAL INSPECTION. <br /> SIGNED ,, .� >r_. �/ ' TITLE ,,z}-<, r '; <br /> ' (DRAW PD T PLAN ON-REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE /FINA INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE 2,20-7 <br /> 3/7b 2M <br /> E H 1426 Rev. 1-74 <br />