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l <br /> /t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORS OFF 'CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;;<- I y3p <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is hereby made to the San <br /> (Complete In Triplicate) <br /> 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 Joa uit <br /> County Ordinance No. 1862 and- the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <> <br /> 1' CENSUS TRACT <br /> Owner's Name r <br /> Phone <br /> Address e-7> <br /> City <br /> Contractor's Name <br /> License # Phone 's-1 . 7,1 <br /> TYPE OF WORK (Check); NEW WELL/� DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION L/ PUMP REPAIR 0 PUMP REPLACEMENT <br /> Other / / _ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT <br /> PROPERTY LINE - PRIVATE DOMESTIC <br /> INNDED USE TYPE OF WELL WELL PUBLIC DOMESTICTWELL <br /> TE <br /> LL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic --- Cable Tool Dia. of Well Excavation <br /> --_.LL_ /private �� Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing <br /> Cathodic Protection Gravel Pack Depth of Grout Seal <br /> Disposal ---._ Rotary Type of Grout <br /> Other Other Information <br /> _____Geophysical -------.-- <br /> Surface Seal Installed $ : <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump j <br /> PUMP REPLACEMENT j% State Work Done <br /> PUMPREPAIRc L State Work Done �t <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Pracedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local He <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN <br /> alth District <br /> after completion of my work on a new well, I will AYS <br /> furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well. in use.. Th <br /> information is true to the best of my knowledge and belief. a above <br />?RIOR TO GROUTING AND A FINAL INSPECTION. g I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> 4PPLICATION ACCEPTED By <br /> ADDITIONAL COMMENTS: DATE ,Z <br /> PHASE II G UT INSPECTION <br /> INSPECTION BY DATE PHASE II FI AL INSPECTIO <br /> INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />