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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFI'ICE 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 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 /> JOB ADDRESS/LOCATION » CENSUS TRACT <br /> Owner's Name Phone <br /> AddressVA&A�_A? <br /> City <br /> Contractor's Name License _ Phor� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION_/ / DESTRUCTION /� _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP A FIELD CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL/-'-EO PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic private Arilled Dia. of Well Casing <br /> Domestic/public TylDriven Gauge of Casing /� <br /> �t Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout � <br /> Disposal Other Other Information Q 1 �� �� <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State 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 TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: <br /> PHA E II GROUT IN CTION PHA,5,L) I/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE .� <br /> E H 1426 Rev. . l-7 <br /> "Iz� �� . V <br />