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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOHOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,-17, �e <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <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 and the Rules an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRizFAi <br /> CENSUS TRACT <br /> Owner's Sty�e &r- 92 3- 7/PhoneAddress <br /> City <br /> Contractor's Name License phone <br /> TYPE OF WORK (Check) : NEW WELL /,V/- DEEPEN / / RECONDITION_/ / DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /-7 PUMP REPLACEMENT /- <br /> Other — <br /> DISTANCE TO NEAREST: SEPTIC TANK 1� SEWER LINES ,7S' 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 <br /> —Domestic/private —4--Trilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation- -� '"- _ —Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -�7-totary - -__ _. Type of--Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> a <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material an 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 HealthDistrict a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is tr to the best of m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> •,G <br />'RIOR TO GRO D A FINAL INSP 0N, <br /> SIGNED �- <br /> 2 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I • <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE &- <br /> ODITIONAL COMMENTS: p - <br /> PHASE II GROUT INSPECTION �S o <br /> INSPECTION BY DATEI PHASE II/F NAL INSPECTION— INSPECTION BY DATE Z- <br /> E H 1426 Rev. • 1-74 �Top d&tl 677 <br />