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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.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 and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION ;Q CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Named " License y Phone 1 � <br /> TYPE OF WORK (Check) : NEW WELL /14--TrEEPEN / / RECONDITION /? DESTRUCTION <br /> TRUCTION / <br /> PUMP INSTLATION �/TPUMP REPAIR / / PUMP, REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC ?TANK _2_j- SEWER LINES '] .r 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 c---Cable Tool Dia. of-Well Excavation ,� <br /> y^omestic rivate Drilled v � f <br /> /P z Dia. of Well/Casing <br /> Domestic/public + Driven Gaugetio€ Casing <br /> Irrigation Gravel Pack Depth-.of -Grout Seal s-p <br /> Cathodic Protection Rotary Type of Grrout C/ el/r-� <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ? <br /> / / State Work Done <br /> 1 <br /> K <br /> b <br /> PUMP -REPAIR: /-7 State Work 'Done ; <br /> i <br /> DESTRUCTION 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 the 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 GRO NG D A FINAI) INSPECTI <br /> SIGNED TITLE <br /> D W-'P' T PLAN `ON RE ERSE SID14 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE - 7 <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />