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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. t� <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 3 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION TRACT <br /> Owner's Name Phone.SA/, �r(7fe <br /> Address ' <br /> City <br /> Contractor's Name 1 <br /> License Phone ! <br /> TYPE OF WORK (Check) ; NEW WELL/T DEEPEN/ / RECONDITION '/—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION Z7/,—PUMP REPAIR / / PUMP REPLACEMENT /-J { <br /> Other / / . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 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 , s t dab le Tool Dia, of Well Excavation o? <br /> Domestic/private` Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 4,:::::-3rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> ^a Disposal Other, Other Information <br /> . . Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP: REPLACEMENT: /. / Stare 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 FORA GROUT INSPECTION <br /> PRIOR TO XROU NG-'.AND A FINAL I P ION. F <br /> SIGNED TITLE <br /> DRAW PL T' PLAN ON REVERSE SID .T,.�. _ r_,�. ,_ i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APi <br /> PLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION . PHASEI I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> E H 1426 Rev. 1-74 3/76 2M + <br />