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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fa:OFFICE USE: V 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone:P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � 5684> <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 and the Rules and Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,Z CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address � � ' , <br /> City <br /> Contractor's Name � <br /> License # (i2 Phone 4:z-' 3-j <br /> TYPE OF WORK (Check): NEW WELL, / DEEPEN/? RECONDITION /—f DESTRUCTION /'7 <br /> PUMP INST L ATION / / PUMP REPAIR '/_7 PUMP REPLACEMENT <br /> Other %// <br /> DISTAN TO NEAREST: SEPTIC TANK �L SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> Industrial 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 /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:— <br /> PUMP <br /> :PUMP INSTALLATION: Contractor ' <br /> r Type of Pump - <br /> H.P. <br /> PUMP REPLACEMENT: . . / / State Work Done �} -•- <br /> PUMP 'REPAIR: %/ State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 FOR A GROUT INSPECTION <br /> PRIOR TO GR. TT G AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRA LOT PLAN ON REVERSE SIDE <br /> PHASE I2 DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED, BY DATE ' <br /> ADDITIO AL CO <br /> F S I O SP ION PHASE III FINAL INSPECTION <br /> INSPECTI BY r DAT INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 f,/7t ou <br />