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SAN JOAQUIN LOCA HEALTH DISTRICT <br /> /G� 1 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. ���� 117 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - � <br /> (Complete In Triplicate) <br /> Application is Aere y made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This a cation is made in compliance with San Joaquin <br /> County ordinance No. 1862 and the Rules and Regu tions of the'San Joaquin Local Health District. <br /> JOB ADDRESS/r 9CTION ` ,, CEN S TRACT <br /> Owner's Na w Phone�� J <br /> Address ' <br /> Jl <br /> Contractor's Nam License e09 <br /> Contractor's / <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / -PUMP REPLACEMENT /_7 <br /> Other <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 /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> T== lustrial Cable Tool Dia. of Well .Excavation <br /> omestic/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 /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: State Work Do <br /> DESTRUCTION OF WELL: Well Diameter Vp Proximate Depth <br /> Describe Material and Procedure -- <br /> 'I hereby agree to comply with all laws and regulations of the San Joaquin Local Health istr ct ,� <br /> ana the State of California pertaining to or regulating well construction. Within FIFTEEN DA <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 LJ/ <br /> ADDITIONAL COMMENTS: -4Z <br /> PHASE II GROUT INSPECTION PHASE III/ Na I S E TION <br /> INSPECTION BY DATE INSPECTION BY <br /> t:7 TT <br /> E H 1426 Rev. 1-74 11.77 2M <br />