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SAN ,70AQUIN LOCAL HEALTH DISTRICT £ � <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � ; <br /> THIS PERMIT EXPIRES l 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 j <br /> and/or install the work herein described. - This application is made in compliance with San Joaquin <br /> County Ordinance No. i 2 av4 the Rules and Rulation o£ the San oa%uin Loc4 Health District. <br /> JOB ADDRESS/LOCATION CENSUS T CT - <br /> ( amer's Name Phone V- �— l e-d <br /> Address City �� y <br /> Contractor's Name License 4 ��a5 Phone - �� <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN / RECONDITION /_/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION / 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 vType of Grout <br /> Disposal. Other: Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor�11� <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 /> _ _.__ r Describe Material and- .Prbcedure ' - . o --- _ <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 GR TING AND NAL INSPECTI N. <br /> SIGNED ._ ' TITLE <br /> k '(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE /FINAL SPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 4 <br /> 2M <br /> E H 1426 Rev. - 1-74 <br /> 6�%7 <br />