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SAN JOAQUIN LOCAL HEALTH DISTRICT �1+ <br /> FOS 'OFFICE USE• <br /> 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 . <br /> ' " 'Date Issued <br /> (Complete In Triplicate)- <br /> Application is hereby made to the San Joaquin Local. Health Districtfnrcoamlpmi <br /> erttoconstruct <br /> and/or install the work herein described. This application is made liance with San Joaquft <br /> County Ordinance No. 1.862 and the Rules and Regulations of- the San Joa uin;Lo 1 He h District. <br /> JOB ADDRESS/LOCATION .1011 <br /> CENSUS. TRACT <br /> Owner's Name <br /> 60, Phone <br /> Address <br /> `City <br /> Contractor's Name <br /> License # Phone - � <br /> TYPE OF WORK (Check): NEW WELL '& DEEPEN/? RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTAL TION _/ / PUMP REPAIR _/ / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 4 � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTENDED USE PUBLIC DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFICATI <br /> _ Industrial Cable Tool Dia. of Well Excavation ONS/ <br /> Domestic/private Drilled 1 <br /> Dia. o£ Well Casing / �� <br /> Domestic/public of <br /> Gauge of Casing 0cv <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 INSTALLATION., -`Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLAN: /�/ State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 put <br /> ting. 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 FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI ) 1 <br /> PHASE I fjt!llso <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B �:7 <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPEC ION PHAS III/FINAL INSPECTION i <br /> INSPECTION BY r /L� ^_ DAT INSPECTION BY <br /> ATE <br /> E H 1426 Rev. 1-74 <br />