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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOn OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. E <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. / <br /> THIS PERMIT EXPIRES l 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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the SanJoaquin Local. Health District. <br /> w <br /> JOB ADDRESS/LOCATION , - / WUS TRACT _ <br /> Owner's Name Phone _ <br /> Address City <br /> Contractor's Name � �'�1 �, / License # 6,7S15rhone <br /> Fes., <br /> TYPE OF WORK (Check) : NEW WELL DEEPEV ,/ / RECONDITION /_/ A�STRUCTION /-7 <br /> PUMP INSTALLATION /}(/ PUMP REPAIR /—/ PUMPEYLACEMENT /� <br /> Other - <br /> - - L.1 <br /> DISTANCE TO 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 C <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout 0 <br /> Disposal Other Other Information p <br /> Geophysical Surface Seal Install.ed_By: <br /> PUMP INSTALLATION: Contractor '� e✓ <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 POUTING AND ZENAL,TNSPECTION. <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 /> PHASE II GROUT INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE --7 <br /> E H 1426 Rev. , l-7 <br />