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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORi''OFFICE 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 1p--2Z-2-�— <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 anddl the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / ,r+ CENSUS TRACT <br /> f �r <br /> Owner's Name _ Phone <br /> Address 0�2`f City ��.� <br /> Contractor's Name t -Gc License #. ,fore Phone �y <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/? RECONDITION /7 DESTRUCTION C j <br /> PUMP INSTALLATION jff PUMP REPAIR /-7—PUMP REPLACEMENT <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 v <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 B : <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump HSP, <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> ,RES TRUCTION 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 thewell in use. The above <br /> information is true to the-hest of my knowledge and belief. I WILL CAU2 FOR A GROUT INSPECTION <br /> PRIOR TOG ING AND INS ECT N <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE W-16-7T <br /> ADDITIONAL COMMENTS: <br /> PHASE t0M INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BYif <br /> jn DATE INSPECTION BY DATE - <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />