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fes. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0T OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. � �a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. o <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 Rule® and Regulations of the San Joaquin Local Health District-. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone22, Ji,31 <br /> Address 4 City <br /> Contractor's Names License # Phone ' <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN 17 RECONDITIOLJ7 DESTRUCTION f <br /> PUMP INSTALLATION "I� PUMP REPAIR' PUMP REPLACEMENT /7 <br /> Other Ll — <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 /> Geophysics] Surface Seal Installed 'B 1 f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.. <br /> PUMP REPLACEMENT: . <br /> / / State Work Done <br /> PUMP .REPAIR• <br /> tate 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 TOG UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE .� <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION.ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P T ' INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> - E H 1426 Rev. 1-74 r Id7q 2M 1 <br />