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SAN JOAQUIN LOCAL HEALTH DiS1"RICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> " Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTIdN OR PUMP PERMIT Permit No. <br /> THIS PERMIT .EXPIRES 1 YEAR,FROM DATE ISSUED Date Issued 7, <br /> (Complete In Triplicate).. , <br /> Application is hereby made t? the San Joaquin Local Health .District fora 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 I Regulations of the San Joaquin Local Health.. District. <br /> JOB ADDRESS/LOCATION . j CENSUS TRACT <br /> Owner's Name Phone <br /> t <br /> Address <br /> City <br /> Contractor's Name _Ivm , L License #211 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION /�PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other 1/ / --- <br /> I <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cablle Tool Dia, of Well Excavation "I <br /> Domestic/private -.i -Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gauge of Casing <br /> Irrigation__ _ I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 .� Rotary Type of Grout <br /> Disposal 1 . Other Other Information <br /> Geophysical Surface Seal Installed By: ` <br /> PUMP INSTALLATION: Contractor <br /> _ .. <br /> ' Type of PumpH.P. <br /> PUMP REPLACEMENT: R <br /> 1 / Sate Work Done""""'" <br /> PUMP .REPAIR: - 1 <br /> State Work 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"raork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify thi m 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 G OUTI AND A.;FINAI --INSPECTION. <br /> SIGNED ~-.x.. x TITLEZZt-t ' r <br /> (DRAW PLOT PLAN ON REVERSE SIVE) <br /> PHASE I t I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> .PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION ' <br /> INSPECTION BY M n DATE INSPECTION BY DATE <br /> �a--- a-til <br /> E H 1426 1 Rev. - I-74 J.7 _ 2lvi <br />