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_ sg <br /> 0 � <br /> SAN. JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USF,: 1601 E. Hazelton Ave. , 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 Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby 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 ,6an Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION <br /> Q �- r f� CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> i <br /> Contractor's Name /lJ �� '�( j,� License /Phone,30 <br /> TYPE OF WORK (Check) : NEW WELL .` DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ - PUMP REPAIR / / PUMP REPLACEMENT /7 # <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C POOL/SEE AGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI TIONS ' <br /> Industrial able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing a :g <br /> Domestic/public Driven Gauge of Casingvls• <br /> rrigation Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: ContractorrCV- )g1liCI pa;;Ip <br /> Type of Pump , H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br />©ES-TRUCTION 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 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 i rue to the besof- my knowledge and belief. I WILL C L FOR A GROUT INSPEC ION <br />?RIOR TO G O AND A. FINA SP TION. . r <br /> SIGNED TITLE r k <br /> (DMOT PLAN ON REVERSE SIDE) i <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> PLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / � t <br /> 1/Z72M <br /> E H 1426 Rev. 1-74 .., �: <br />