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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.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 f7`Z <br /> (Complete In Triplicate) <br /> Application is hereby made tc 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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q sof 4. CENSUS TRACT <br /> Owner's Name Phone <br /> Address �9'» City <br /> { <br /> J <br /> Contractor''s. Name .5,eG License # Phone t <br /> TYPE OF WORK (Check) : NEW WELL/ f DEEP N / / RECONDITION /_% DESTRUCTION /- <br /> PUMP INSTALLATION �FUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE 6 ISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER M <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 i Drivenko', Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection rRotary - . Type- of 'Grout' <br /> Disposal i Other Other Information <br /> Geophysical ! Surface Seal. Installed By: <br /> PUMP �INSTALLATION: Contractor <br /> Type of Pump DP ;+. Sel, H-P,. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / SIate Work Done <br /> DES-TRUCTIO_N OF WELL: Well Diameter �_ Approximate Depths <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 regulatirig"we11 ''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 puttingthe 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 / <br /> ADDITIONAL COMMENTS: 0 Ae <br /> PHASE II GROUT INSPECTION�,. ^�^""" '� P E I I/ I AL-INSPECTION <br /> INSPECTION BY^ "DATE-.-- INSPECTION BY - DATE <br /> r <br />,. <br /> 2M <br /> E H 1426 Rev. 1-74 1fZ7 _ <br />