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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: I� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br />' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. �� <br /> THI#S 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 Jopquin <br /> County Ordinance No. 1862 and. the Rules and Regulations of the San Joaquin Local Health District. <br />' JOB ADDRESS/LOCATION �� k <br /> Y CENSUS TRACT <br /> Owner's Name <br /> - Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License # �7iPhone � � <br /> l <br /> t _ i <br /> TYPE OF WORK (Check) : NEW WELL '/ I DEEPEN '/—/ RECONDITION / / DESTRUCTION /77 <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 6 <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Irrigation <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation k 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 <br /> Type of• Pump H.P. <br /> PUMP REPLACEMENT; Std to Work Done ., TAat+ <br /> PUMP .REPAIR: St;ate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure p <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 /> informatio is true to the best of my..knowledge and belief. I WILL CALL FOR A GR2T INSPECTION <br />?RIOR TO GRO TING A5B FINAL 1ASPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 1 <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> kPPLICATION ACCEPTED BY Q �f7 DATE <br /> 4DDITIONAL COMMENTS: r -- <br /> PHASE II GROUT INSPECTION P SE /FIN INSPEC <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 lJ77 9m <br />