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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEltOFFICE -USE: 1641 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 6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local .Health District for a permit to construct <br /> axed/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 �� CENSUS TRACT <br /> Owner's Name -I j Phone <br /> Address <br /> city ,J <br /> Contractor's Name License <br /> 0/a Phone <br /> - s <br /> TYPE OF WORK (Check):.- NEW-WELL L-_7 DEEPEN-./7—RECONDITION -/-7- DESTRUCTION - <br /> PUMP INSTALLATION I I PUMP REPAIR/ Z ` PUMP REPLACEMENT— <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <br /> SEWAGE DISP05AL FIELD CESSPOOL/SEEPAGE PTT OT�iER J <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CON5TRUCTION SPECIFICATIONS <br /> �_ Industrial Cable Tool Dia. of Well .Excavation <br /> Domestic/private- . - 'Diilled Dia. of Well Casing <br /> Domestic/public . G� <br /> Driven ' <br /> �wuge of Casing <br /> Irrigation Gravel Pack -1 � • <br /> Depth of Grout Seal <br /> Cathodic Protection Rotary -- Type of Grout <br /> Disposal i � Other - <br /> �,,� Other-Information <br /> �Geophysicalsurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: •�' <br /> // State Work"-Done • <br /> _RUN]P :REPAIR: -" <br /> Y.. , State -Work Done C <br /> ES'PRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> E <br /> I, hereby agree to'comp y 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 furbish the San Joaquin.Local_Health District a <br /> WELL DRILLERS REPORT of the well and notify them befoke putting-the- well in use.. The above <br /> information is true to the—best—of my-knowledge and belief. <br /> PRIOR TO GR UTIN AND F I WILL CALL FOR A GROUT INSPECTION N <br /> AL INSPECTION. <br /> SIGNED <br /> TITLE <br /> PLOT PLAN ON REVERSE SIDE , <br /> PHASE I t' f <br /> FOR DEPARTMENT USE ONLY <br /> PLICATION EP <br /> ACCTED <br /> APBY ' Y <br /> ADDITIONAL COMMENTS: <br /> DATE <br /> f-, PRSE II GROUT INSPECTION PHA III N INSPECT <br /> INSPECTIONSY . DATE INSPECTION. BY DATE <br /> 2 <br /> E H 1426 Rev. -74 <br />