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FOR SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Pi(,1�,�,ld e-' THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED <br /> Qom. Date Issued <br /> {Complete In Triplicate) <br /> Application is herby 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 lam/ <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City ' <br /> Contractor's Name � �^ � , <br /> License # e '.phone, <br /> TYPE OF WORK (Check): NEW WELL '/? RECONDITION DEEPEN '/? <br /> PUMP INSTALLATION /_7 DESTRUCTION f f <br /> X PUMP REPAIR '/� PUMP REPLACEMENT /7 <br /> Other C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPO AL FIELD PIT PRIVY <br /> PROPERTY LINE - PRIVATE DOMESTIC SWELL�SEEPAGE PUBLTC i`ESTI <br /> DO OTHER . <br /> INTENDED USE TYrE OF WELL C WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS I <br /> Cable Tool Dia. of Well Excavation <br /> ---4 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 <br />__Geophysical -..,�.�__ Other Information <br /> Surface Seal Installed By., <br /> PUMP INSTALLATION: Contractor � • <br /> Type of Pump <br /> &.P. <br /> PUMP REPLACEMENT %/ State Work Done <br /> PUMP.'REPAIR: / / State Work Done <br /> DE&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 /> 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 WI <br />'RIOR TO GROUTING AND A LL CALL FOR A GROUT INSPECTION <br /> F' N INSPECTION. <br /> 5IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'LASE I FOR DEPARTMENT USE ONLY <br /> AFP ATION' ACCEPTED By <br /> IDDITIONAL COMMENTS: DATE 0 <br /> PHASE II GROUT INSPECTION P IiFINAL INSPECTION <br /> INSPECTION BY I <br /> INSPECTION BY DATE <br /> DATE <br /> E H 1426 Rev. 1-•74 <br />