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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ' 1601 E. Hazelton Ave, , ,Stockton, Calif, <br /> Telephone : <br /> APPLICATION FOR WELL CONSTRUCTION 6OR1PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> I - (Complete In Triplicate) <br /> Application is G reby 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. 1$62 and the Rules 11111and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . . <br /> a CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address , <br /> k City /.- _ C�� ._ <br /> Contractor's NameLicense �� <br /> �� hone ' " <br />. TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /-7 RECONDITION /_7 DESTRUCTION t <br /> PUMP INSTALLATION _ C / <br /> / / PUMP REPAIR / / PUMP REPLACCEMEEME NT_ <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 <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private 1 Drilled Dia, of Well Casing <br /> Domestic/Irrigation <br /> ! Driven Gauge of Casing p9 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ~� <br /> Geophysical <br /> Surface Seal Installed By: (D <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump <br /> H.P. i <br /> PUMP REPLACEMENT: / State Work Done \ <br /> k _ � <br /> LUIL,.REPAIR: /7 State Work Done <br />)ES•TRUCTION OF WELL: Well Diameter <br /> Describe,Material and Procedure Approximate Depth <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 /> 4ELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> Cnformation is true to the best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GRO NG AND A F AL. T S, ION. <br />>IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> - ; <br /> rPPLICATION ACCEPTED BY <br />,DDITIONAL COMMENTS: <br /> DATE J5=7 7 <br /> PHASE I ROUT INSPECTION <br /> �� <br /> TPHABIII SINAL TNSPECTT.NSPECTION BY DATE INSPECTION BDATE <br /> E H 1426 Rev. 1-74 11,27 <br />