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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FORIOFFTCE USE: 1601 E. Haxelton.Ave. , tStockton, 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 Trip�.icate) <br /> Application 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 San Joaquin:Local 'Health District. <br /> Y.5' 2- ,,-j. 1®�v,,c,� ^ Y2� r <br /> .70E ADDRESS/LOCATION 0& '0 (,?1`2-9v <br /> y <br /> `'r t CENSUS TRACT <br /> Owner°s Name ,, <br /> Phone <br /> Address <br /> City ".. i <br /> Contractor's Name " <br /> - License # Phone <br /> TYPE OF WORK (Check): NEW WELL -/? DEEPEN -/7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION -7 PUMP REPAIR � PUMP REPLACEMENT. /_7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> . PIT PRIVY � 1 <br /> SE6dAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTR <br /> PROPERTY LINE -- PRIVATE bOMESTiC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL C � <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private � . � Drilled � Dia. of dell Casing <br /> IrriDomeajion llc Driven Gauge of'Casing <br /> Irxigaion Gravel Pack Depth of.Grout Seal <br /> Cathodic Protection Rotary .Type of Grout <br /> -Disposal _�� Other Other Information � <br /> -Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 't <br /> Type of Pump <br /> *; H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />_P r <br /> State Work" '- <br /> ...._ Don'e. <br /> E&TRUCTION OF WELL: Well Diameter <br /> i <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Lgcal 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 Sail 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 <br /> PRIOR TOG OUTING AND A FINAL INSPECTION.. CALL FOR A GROUT INSPECTION4 <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> �` � FOR DEPARTMENT USE.ONLY <br /> PHASEI <br /> ' PLICATMON ACCEPTED `BY <br /> ADDITIONAL COMMENTS: DATE - IV <br /> ,PHAS jG OUT INSPECTION ASE FIN INSPECTION <br /> INS 'ECIONPH <br /> BY�'; _: DATE <br /> A <br /> _ INSPECTION BY TE -- <br /> E H 1426 Rev. 1-74 <br />