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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - <br /> FOF OFFICE USE: 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 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. L(J. ,4, l CENSUS TRACT <br /> Owner's Name t i. Phone <br /> r City <br /> Address` o -�— <br /> Contractor's Name /�y,¢ � License #1423 2-3 Phone3 j0 m <br /> w <br /> TYPE 0 WORK_(.Check)_: NEW WELL.{ - DEEPEN / /_L_RF.Cblfb'TION- /--/__DESTRUCT-ION <br /> PUMP INSTALLATION �:J PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / ■ <br /> DISTANCE TO NEAREST: SEPTIC TANK -` Z SEWER LINES �O _ PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD 717'. CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY- LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED •USE .. TYPE OF WELL CONSTRUCTION SPECIFICATIONS (fvp <br /> Industrial § _ iCable Tool Dia. of Well Excavation D I' <br /> Domestic/private - Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal 3-b <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed II <br /> TI <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump _ H.P. f <br /> PUMP REPLACEMENT. / / ' -S-tate Work Done <br /> I. PUMP REPAIR: / / State 'Wdrk.Done <br /> DESTRUCTION OF WELL: Well Diameter 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 rue to the b st of- my owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G A F L INSPEC ON. <br /> SIGNED TITLE <br /> Sd PLOT PLAN ON REVERSE SIDE) <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ti BATE <br /> ADDITIONAL COMMENTS: <br /> M PHASE II GROUT INSPECTION PHASE I /FINAL INSPECT ON <br /> INSPECTION BY DATE ,:..INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. - I-74 '° <br />