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SAN JOAQUIN LOCAL HEALTH. DISTRICT ` <br /> FO&OFFICE V 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 t• <br /> � Bate Issued <br /> Appli (Complete In Triplicate) <br /> cation is he 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 /> Caunty- Ordinance No: 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> JOB ADDRESS/LOCATION V B 17 Al <br /> CENSUS TRACT <br /> Owner's Name 11® <br /> Phone " <br /> Address <br /> Contractor's Name ` <br /> License <br /> %. Phone /'.2 <br /> TYPE OF WORK (Check) : NEW WELL -/DEEPEN / / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION —/ / PUMP REPAIR / / PUMP REPLACEMENT' /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Al EWER LINES PIT PRIVY .. <br /> SEWAGE I DISPOSAL FIELD k� CESSPOOL/SEEPAGE PIT ., OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> Industrial <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Carle Tool Dia, of Well Excavation IK ' <br /> Domestic`/private <br /> Drilled Dia. of <br /> Domestic/public Well Casing / r/ <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal moi`_ u— <br /> Cathodic Protection Rotary Type of Grout `< <br /> Disposal Other Other Information <br /> Geophysical - - <br /> '"� d►,'`"'�. Surface Seal Installed $ <br /> PUMP INSTAL1;ATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: , <br /> / / State Work Bone � • <br /> PUMP1 t <br /> REPAIR: /. / State Work Done <br /> *: <br /> DESTRUCTION OF WELL:. Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 welland nYotif. them before putting the well in use. The above <br /> information is true -to .the best of. my-knowl�4ge,,and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPECTI '� <br /> SIGNED <br /> TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE} -r— <br /> PHASE: I, <br /> • FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY # <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE tINSPECTION BY <br /> DA <br /> E H 1426 -.Rev. <br />