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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR "OFFICE USE: I1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> (APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> I <br /> THIS PERMIT EXPIRES 1 -YEAR.FROM DATE ISSUED Date Issued <br /> (Complete InTriplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a,permit to construct <br /> C and/or install the world 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 IVA 11. <br /> P <br /> ENSUS TRACT <br /> Owner's Name � <br /> Phone <br /> Address !� <br /> City <br /> I'. Contractor's Name <br /> i� License honk � � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION /— <br /> Other / 7 �/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �/MSA <br /> RIVY <br /> SEWAGE DISPOS L FIELD CkSSGE PIT OTHER <br /> PROPERTY LINEMPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE i TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> � I �-�• <br /> i Cable Tool Dia, of Well Excavation 5j <br /> Domestic/private ;, YDrilled Dia. of Well Casing <br /> i <br /> Domestic/public iDriven Gauge of Casing <br /> Irrigation ' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> � •^"_"7" y Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> j Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P. . — <br /> PUMP REPLACEMENT: , /.,M / State Work Done <br /> PUMP .REPAIR: /IM / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyllwith 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 GROUTING AND A riINAL INSPECTION. <br /> SIGNED TITLE <br /> :r (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ,I- GROUT INSPECTION PHA�_Sz UI FINAL INSPECTION <br /> INSPECTION BY .!M DATE INSPECTION BY DATE <br /> I <br /> E H 1426 Rev. I-74 j 6� 2M � <br />