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1�0 + ' a SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> Or, FFIC8 USE: 1601 E. Hazelton Ave. ,- Stockton, Cali , <br /> Telephone: (209) 466:678 44 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> G <br /> i 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION D a-a CENSUS TRACT --- =r� <br /> Owner's Name &,gPhone <br /> Address City <br /> 4 Contractor's Name License ��Phonen <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION_/7 DESTRUCTION /-7 <br /> I PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> 1 <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 <br /> Domestic/private Drilled Dia, of Well Casing OM <br /> c <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> r Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate .Depth <br /> Describe Material- and Procedure — <br /> I comply ree a herebY B p Y to 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting.- thewell 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 FI AL INSPECTION. � <br /> SIGNED TITLE /1�� �J _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 4 <br /> ADDITIONAL COMMENTS: <br /> P E GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ;-(�-�'� - INSPECTION BY j + _ DATE jp <br /> E H 1426 Rev. - l-74 6%/7 <br />