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w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 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 'herdby 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 Jo4quin <br /> County Ordinance No. 1862, and the Rules and .Regulations of the San joa,l,ui cal Health District. <br /> h�� 4 E'i►7y I <br /> JOB ADDRESS/LOCATIO f ' <br /> ch F TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contct 's Name License #pFhone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/�EPEN / / RECONDITION /_7 DESTRUCTION /_ <br /> r-,° PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE:TQ .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 16 ,0 4 <br /> Irrigation Gravel Pack Depth of Grout Seal _4 F _ <br /> Cathodic Protection x Rotary Type of Grout ' ' <br /> Disposal Other Other Information- r <br /> Geophysical Surface Seal Installed _B .- <br /> PUMP INSTALLATION: Contractor S -� <br /> Type of Pump *k ,� H.P. ` <br /> _ -a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> / / State Work Done <br /> — 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material-,.And Procedure i <br /> t <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'FDRILLERS 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 G OUTI ANP A FLVAL N. <br /> SIGNED . TITLE 1;1 '+ <br /> (}RAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLI-CA-T.ION-ACCEPTED-BY- : r. - ' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 4 PHASE III/FINAL INSPECTION: <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> a C T3 <br /> E H' 1426 Rev. 1-74 � ' 1/77 - � <br />