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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �'OFi,OFFICE USE: � f 1601 E. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 13-Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> '1 <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`vand <br /> �ythe Rules and Regulations of th San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` ! a C � CENSUS TRACT <br /> Owner's Name Phone <br /> Address 1 � �� C � /i'L City <br /> Contractor's Name <br /> � .License #,:UiC41 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / ON <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 <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ::�7^ ` <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 best of my knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TO,GROUTING A FINAL INSPECTION. <br /> SIGNED TITLEa Zzf_1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR EPARTMENT USE ONLY <br /> ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II ®/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYG✓ �1ATE �Z3-77 <br /> / , , <br /> E H 1426 Rev. 1-74 1177 2M <br />