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V,6,J SAN JOAQUIN LOCAL "HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave <br /> 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 <br /> Date Issued <br /> (Complete:-In Triplicate) <br /> Application is hereby trade 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 'he San Joaquin Local Health District. <br /> j JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> zz Phone 7 <br /> Address .77 <br /> City4% <br /> Contractor's Name fQr w <br /> License #oZj p Phone ? <br /> TYPE OF WORK (Check-)-.0--NEW- /?—DEEPEN-/--7.RECONDITION-/?DESTRUCTION /_7 _ = - <br /> PUMP INSTALLATION REPAIR /—/ PUMP REPLACEMEN7T <br /> Other/ <br /> DISTANCE TO NEAREST: SE PTICTANK <br /> SEWER LINES PTT 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 /> IndCONSTRUCTION SPECIFICATIONS <br /> ustrial l Cable Tool Dia. of Well Excavation— <br /> Domestic/private # Drilled i. Dia. of Well Casing <br /> Domestic/public <br /> ______ <br /> Driven .p Gauge of Casi � <br /> Irrigation Gravel Pack ng <br /> Depth of Grout Seal <br /> Cathodic Protection . 1. Rotary < Type of Grout' v <br /> Disposal ' Other Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done - <br />" PUMP :REPAIR: <br /> - 4 <br /> ES7RUCTION OF WELL: Well Diameter t <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply witheall laws and regulations of the San Joaquin Local Health District <br /> and the State of_California.-pertaining--toter---regulating well canstzucti ft—•Witham FIFTEEN DAYS <br /> after completion-of,my work. on;a �new well, I will furnish the San Joaquin Local Health District a a <br /> WELL DRILLERS REPORT of the well'and notify them befoie Puttig-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 GROUT G AND A FI SPECTION: <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE -- t <br /> PHAS$ I t - `' FOR DEPARTMENT USE ONLY <br /> l"' .� : ! <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE — <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHAS II . ' IN INSPECTION <br /> " .� -_ _ DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />