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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Pi III USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. / Ss <br />! THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 instar, 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 /> i JOB ADDRESS/LOCATI 61� � <br /> CENSUS TRACT <br /> Owner°s Name A-2 <br /> ��� PAddress IfCContractor's Name6 <br /> License /� <br /> TYPE OF WORK (Check): NEW WELL /-" DEEPEN /_7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR _0PUMP PUMP REPLACEMENT %f <br /> Other j/7 <br /> DISTANCE TO NEAREST: <br /> SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> OTHER <br /> INTENDED USE TXPE OF WELL PUBLIC DOMESTIC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> Domestic/public Dia. of Well Casing <br /> _ public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� Rotary Type of Grout' <br /> Disposal w _�� Other <br /> Geophysical. ..- ..-.�� Other Information <br /> Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP :REPAIR: �¢ <br /> mak` State Work Do <br /> -. <br /> E&TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health DCrict <br /> ' <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 4 <br /> -well and notify them before put ting-the- well in-use.. The above <br /> WELL DRILLERS REPORT of the <br /> information is true to the-best of my-knowledge and belief. Z WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTTNG AND A FINAL INSPECTION. <br /> SIGNED ? ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE A <br /> PHASE I FOR TMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BYPHASE I I F NAL INSPECTIODT <br /> DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 .... <br />