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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br />` Telephone: (209) 466-6781. <br /> ff <br /> /APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7zl-1 9 dlo <br /> I, <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 CENSUS TRACT <br /> Owner's NamePhone <br /> s <br /> Address City <br /> Contractor's Name <br /> License <br /> P <br /> hone . .� <br /> Y - - -- - - <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -1-7 RECONDITION• _ <br /> l.�T I7 /� DESTRUCTION /� <br /> PUMP INSTALLATION /� PUMP REPAiR` ,� PUMP REPLACEMENT � . <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 0 CONSTRUCTION SPECIFICATIONS <br /> .Industrial4 Cable Tool : Dia, of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/pub2icI, p �_ <br /> "� Driven g. Gauge of Casing <br /> Irrigation Gravel-Pack of Grout Seal <br /> `Cathodic Protection Rotary Type of Grout' V - <br /> Disposal _ Other_ Other Information -- _ <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> A Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />" <br /> -PUMP .REPAIR: "" State Work Done i <br /> PES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> if 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 GROUTIAG ANDA INAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> ` (DRAW PLOT PLAN ON REVERSE SID <br /> FO DEP T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 4 1VE H 1426 Rev. 1-74 ` I-7A IM <br />