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�J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FOE,Q.FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7� <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 an' oaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name , Phone <br /> - 1 <br /> Address City_ <br /> Contractor's Name LicenseOka <br /> Phone <br /> PF <br /> i <br /> TYPE OF WORK (Check) : NEW WEL DEEPEN '/—/ RECONDITION /�/ DESTRUCTION /-7PUMP I ST�AL ,TION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other V / <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 1 Cable Tool Dia, of Well Excavation <br /> Domestic/private { Drilled Dia, of Well CaZal' <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout dq f Q� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informatia <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION; Contractor * <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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. T above <br /> information is true to the best of my.-knowledge and belief. I W LL'-CUL FOR A GROU INSPECTION <br /> PRIOR TO GR U NG AND A FIN SPECTION. <br /> SIGNED TITLE <br /> DRAW P T' PLAN '0N REVERSE SI <br /> PHASE I FOR DEPARTMENT USE ONLY <br />' APPLICATION ACCEPTED BY�. DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE I GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE / �7 <br /> E H 1426 Rev. 1-74 3/76 2M <br />