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FOR_ OFFICE USE: ' n SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> 4,/ 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �_� <br /> I <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED <br /> Date Issued ] <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instar 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 .Toaquin Local Health District. <br /> JOB ADDRESS/LOCATION A/Mv <br /> '' CENSUS TRACT j <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License � <br /> .� ���Phane <br /> TYPE OF WORK (Check) : NEW WELLi <br /> DEEPEN%% REPLACEMENT <br /> RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION —/—/ PUMP REPAIR / / PUMP <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYsLINE -- PRIVATE DO <br /> INTENDED USE MESTIC WELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCON SPECIFICATIONS <br /> , o <br /> Industrial ► Cable Tool Diaf Well Excavation <br /> Domestic/private Drilled <br /> Domestic Dia. of Well Casing <br /> /public . : Driven Gauge of Casing <br /> Irrigation ! Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection I Rotary Type of Grout n <br /> Disposal ' Other Other Information <br /> Geophysical 1 Surface Seal Installed By: <br />'UMP INSTALLATION: Contractor <br /> Type of.,Pump <br /> 1 H.P. 1.- <br /> 1 �j <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP .REPAIR: <br /> State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe#Material'and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District i; <br /> nd the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br />€ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> aformation is true to the best ,of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> LIOR TO G TING ANDA INAL INSPECTION. <br /> CGNED' y � <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> tA.SE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY �1 y <br />)DITIONAL COMMENTS: DATE - <br /> �1 <br /> PHASE II GROUT INSPECTION PHASE II . /FINAL INSPECTION <br /> ISPECTION BY V DATE;, INSPECTION`BY <br /> V ! r /�. .._ /, DATE 1? <br /> E H 1426 Rev. 1-74 <br />