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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR�OFFICE USE: j/ 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 <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 nd th R I and Regulations of the San Joaquin Local Health District . <br /> �707 S�9 s <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Nam <br /> � Phone <br /> Address City <br /> Contractor's Name License hone Y:127)'— <br /> TYPE OF. WORK .(Check): NEW WELL /-7 DEEPEN -/-7 RECONDITION /—j DESTRUCTION ^� <br /> PUMP INSTALLATION /7 PUMP REPAIR /7 PUMP REPLACEMENT /7 a <br /> Other / J <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 <br /> Domestic/public Driven Gauge of Casing <br /> i Irrigation 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: / / State Work Done <br /> PUMP :REPAIR: /-7 State Work Done _ .. <br /> ESTRUCTION OF WELL: Well Diameter / �. Approximate Depthw <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 I <br /> PRIOR TO GROUTI D A FINAL PECT N. 1 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F EPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> G ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE 1I INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> k . <br /> E H 1426 Rev. 1-74 1-71. 9M <br />