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lv� SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 ons of t San Joaquin Local Health District. <br /> f <br /> JOB ADDRESS/LOCATION / /CENSUS TRACT <br /> Owner's Name a Ef � DG�Id✓C�' � ' e ! / <br /> . �Address City ��`-7 <br /> Contractor's Name Licen) ;� <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP ItiSTALLATtON /_/ PUMP REPAIR _0 PUMP REPLACEMENT_ f7 <br /> Other <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 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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed„ BX: <br /> PUMP INSTALLATIONt Contractor i <br /> . Type of Pump H.P. , <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPtREPAIR: / State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> X hereby agree to comply with alb, 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 FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT WSPECTION PHASE T T FINAL INSPECTION r <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1.-74 1-74 2M <br />