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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --P-09-­OFFICE U E: 1� 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 Regulations of the S n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name c1Phone �_� <br /> Address � � � � ,���-� City <br /> Contractor's Name dZZ License �h` d�� Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ 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 /> Industrial Cable Tool Dia. of Well Excavation , <br /> Domestic/private Drilled Dia. of Well Casing �1 <br /> Domestic/public Driven Gauge of Casing (A <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 B : a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P. -a <br /> PUMP REPLACEMENT: / / State Work Done i=-� 6-A. / <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 CALJ, FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AN F NAL INSPE TIW. I,1 <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) T <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `` -7-13-7 <br /> / -7 <br /> APPLICATION ACCEPTED BY t Je DATE 7' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE?/ td <br /> E H 1426 Rev. 1-74 <br /> 1 IV 2M <br />