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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue d��� <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. 1$62 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> AOJ gym <br /> JOB ADDRESS/LOCATION JA <br /> � `' e �" 1,�� I�.t�-� CENSUS TRACT 0(_3-0e.0-_5'o <br /> Owner's Name r Phone�4• 4�`7 � <br /> Address 6 7 City <br /> Contractor's Name License # Phone <br /> p <br /> Q <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/--PUMP REPLACEMENT <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 /> INTENDED USE TYPE OF WELL blCONSTRUCTION SPECIFICATIONS <br /> Industrial - - Cae Tool " Dia, of"Nell-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 sQ <br /> Type of Pump �"�-=-�'„ -� ?—..._.. H.P. ? <br /> PUMP REPLACEMENT: f /' State Work Done. <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 the. well in use.. The above <br /> information i true to the best of my k owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GR IN AND AL INSPE N. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> PHASE I OR DEPARTMENT USE ONLY . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT INSPECTI N PHASE III/FINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - l-74 2M <br />