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E FOB70PPICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. <br /> , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permit <br /> and/or install the work herein described. This application is made in compliance,to construct <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health n Joaquin <br /> JOE ADDRESS/LOCATION District. <br /> Z <br /> CENSUS TRACT <br /> Owner's Name IA/ <br /> Phone <br /> Address <br /> City . � <br /> Contractor's Name <br /> License # _ Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/? RECONDITION /_7 DESTR <br /> PUMP INSTALLATION-/ / PUMP REPAIR REPLACEMENT <br /> Other ��.PUMP REPLACEMENT ] <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> SEWER LINES � PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD _ <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTEND USE <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> . DETYPE OF WELL <br /> Industrial GONSTR[]CTION SPECIFICATIONS <br /> Domestic/private ---�— Cable Tool Dia. ofWell Excavation <br /> Domestic Drilled Dia. of <br /> Well Casing <br /> /public ��" Driven <br /> Irrigation Gauge of Casing <br /> Gravel Pack <br /> Cathodic Protection Depth of Grout Seal <br /> Disposal Rotary Type o€ Grout <br /> Other O <br /> Geophysical _. ther IAformation <br /> -Surf tce Seal Installed 'B <br />'UMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. 4 <br />'UNP REPLACEMENT: / / lState Work Done 1 <br /> UMP 'REPAIR: <br /> L/ State Work Done <br /> E&TRUCTION OF WELL: Well Diameter �{ <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations Health Dis C <br /> ad the State of California pertaining to or regulating well ''construction. Within FIFTEEN <br /> of the San Joaquin Local <br /> DAYS <br /> Eter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them.-before 'Put <br /> ting- the.-well- in-use..,. The above <br />'formation is true to- the-best -of my.-knowledge and belief. I WILL CALL FOR <br /> A FINAL INSPECTION. A GROUT INSPECTION <br />;IOR TO G OUTING AND <br /> CGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br />[ASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br /> iDITIONAL COMMENTS: 5 � crjD'ATE <br /> o �PHASE 11 GROUT INSPECTION <br /> 7 <br /> ��r a. I4 <br /> .SPECTION BY PHA I FINAL 1E SPECTiONINSPECON BY <br /> DATE <br />`WH- 1+226 _�* . „ <br /> Rev: 1-74 <br />