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411 f' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: t ,' 1601 E. HazeltonAve. ," 'Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �U\ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �(J (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 <br /> Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / d e�10ENSUS TRACT <br /> Owner°s Name Phone <br /> Address City <br /> Contractor's Name License97? Phone <br /> PCXR <br /> TYPE OF WORK (Check): NEW WELL/-V DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR/-7 PUMP REPLACEMENT /7 <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 q�V <br /> Industrial Cable Tool Dia. of Well Excavation \1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> omestic/public Driven Gauge of Casing /�2 - <br /> Irrigation �Gravel Pack Depth of Grout Seal <br /> Cathodic Protection RotaryType of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor O /ia n/4-104, <br /> Type of Pu H.P. 6. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP *.REPAIR: /7 State Work Done _ <br /> ,RES•TRUCTION OF WELL: Well Diameter Approximate Depth1646 <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 thewellin 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 GROUTINF, .AND A FINAL I PE CT N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I 2 <br /> FOX bEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B S/ L DATE 'Z� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> H 1426 Rev. 1-74 1-74 2M <br />