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SAN JOAQUIN LOCAL HEALTH DISTRICT - -- <br /> � :., <br /> FOR;, USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �j6 -73)"' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1 (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 />` I <br /> E JOB ADDRESS/LOCATION ,j <br /> f CENSUS TRACT <br /> G Owner's Name Phone <br /> f <br /> Address f <br /> City <br /> Contractor's Name Licensey�l Phone3/ <br /> TYPE OF -WORK (Check): NEW W$7 7DEOEPEN /? RECONDITION / DESTRUCTION / <br /> PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT- <br /> Other l/ / 1 <br /> DISTANCE TO NEAREST: SEPTIC °TANK SEWER LINES 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 i Cable Tool Dia. of well Excavation <br /> Domestic/private t Drilled Dia, of Well Casing \ . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation iGravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> ,,,_Disposal Other Other Information <br /> Geophysical -- Surface Seal Installed BX: ; <br /> PUMP INSTALLATION: Contractor o 1 <br /> Type of Pump +. <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> :PUMP .REPAIR: <br /> 1-7 State Work bone <br /> ESTRUCTION OF `WELL: ZAD <br /> Wproximatedh °E <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall laws and regulations of the San Joaquin Local H al 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 G TING A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> !- (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APDL A ION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: V1 Z 1117 X <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY <br /> - DATE.?-// - <br />.Y <br /> E H 1426 Rev. 1-74 <br />