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xoiRlOFFICE USE• I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> x601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> f (Complete In Triplicate) <br /> Application is her made to the San Joaquin Racal Health District for a permit to construct <br /> and/or install the work herein described: Thid 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/LOCATI -il <br /> CENSUS TRACT <br /> Owner°s Name C <br /> -- _ <br /> p Phone <br /> Address p " i 4 <br /> ip City - <br /> Contractor's Name r , 9L . : <br /> License # Phone 4,a� -) <br /> TYPE OF WORK (Chedk): NEW WELL DEEP / RE <br /> � CONDiTIQN /� DESTRUCTION /� - <br /> PUMP INSTALLATION /�_�UMP REPAIR /—/—PUMP REPLACEMENT %T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> TYPE OELL`• GONSTRUCTIQN SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation.. <br /> 4lDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Sea . _ <br /> Cathodic Protection Rotarya of Grout <br /> Disposal. - i Other <br /> N' <br /> Other Other Information <br /> Geophysical r 'Surf ace Seal Installed BY: <br /> PUMP INSTALLATION: <br /> Contractor. ` <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: Ell / State Work Done <br /> . . al � <br /> PUMP !REPAIR: /moi State Work Done _ <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth ' <br /> hereby agree to complyj�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 j <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 GR TING AND A FINAL PECTION: <br /> SIGNED <br /> TITLE <br /> M (DRAW PLAT PLAN ON REVERSE SIDE) <br />_PHASE JI <br /> -- FOR DEPARTMENT USE ONLY <br /> APPLICAfiION ACCEPTED BY ;!' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY �j DATE INSPECTION BY <br /> i� DATE <br /> E H 1426 Rev. 1-74 �� <br />