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t SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r' 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regul�ons_„f the '87L/o,quip Local Health Distriet.'t <br /> JOB ADDRESS/LOCATION �� LL�� CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License lj��Phone <br /> TYPE OF WORK (Check):: NEW WELL / / DEEPEN '/_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> 0 ther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER of <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL K PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS !_ <br /> Industrial Cable Tool Dia, of Well excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation 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: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMF -.REPAIR: / / 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 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 is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING:AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> c (DRAW PLOT PLAN ON REVERSE SIDZ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY qlczrbDATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INS CTION PHAS I / INSPECTION <br /> INSPECTION BY DATE INSPECTION BY iDATE - ZZ,4 <br /> E H 1426 Rev. . 1-7A - <br /> 67.7 _ 2M <br />