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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi *OFFYCENSIE44' 1601 E. Hazelton Ave., Stockton, Calif. <br /> * Telephone: (209) 466-6781 <br /> r 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 h reby 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 Joaqj4n <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _1f �� �C , L <br /> CENSUS TRACT <br /> Owner's Name �o�nn� ,� �z7t �,✓ Phone <br /> Address Da / City <br /> Contractor's Name / �,� moi License # ZZ2323Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITI N /7 DESTRUCTION /-1 <br /> PUMP INSTALLATION/—/ PUMP REPAIR f PUMP REPLACEMENT jg <br /> Other /-7 <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 ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ._..� Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PiT d REPLACEMENT:— %/ State Work Done <br /> PUMP .REPAIR: State Work Done rr <br /> • Q `1 <br /> DESTRUCTION OF WELL: Well Diameter / Approximate Depth A <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 /> FRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� ;, DATB <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION '" PHASE III/FIVAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H1426 Rev. 1-74 <br />