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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0__S7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,':: ?- $ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued _��77 <br /> (Complete In-Triplicate) <br /> Application 'is hereby made to the San Joaquin Local Health District for a permit to construct <br />'k and/or instal, 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 fQn CENSUS TRACT ` <br /> Owner's Name r Phone <br /> Address <br /> City '- <br /> Contractor's Name _ <br /> - License Phone <br /> TYPE OF WORK (Check): NEW WELL -%7 DEEPEN J7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION J1; PUMP REPAIR -/_7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 74,- omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP. INSTALLATIONo Contractor ! ` <br /> Type of Pump <br /> H.P. <br /> ,r <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 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 GROUTIN AND"A FINAL, INSPECTION. <br /> SIGNED TITLE <br /> i` (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 4 - <br /> APPLICATION' ACCEPTED BY DATE , <br /> iADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. . <br /> NSPECTION PHASE III !� AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H-1426 Rev. 1-74 h/75 2M <br />