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SAN JOAQUIN LOCAL HEALTH DISTRICT - '-- <br /> FOR�+aFFICE USE: 1601 E. Hazelton Ave. <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application" is hereby made to the Salt 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 San Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION <br /> 10 CENSUS TRACT <br /> Owner's Name <br /> Phone [� <br /> Address <br /> C:ity ..j <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN/7 RECONDITION /_7 DESTRUCTION <br /> M PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other / / <br /> A _ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE USE PIT OTHER <br /> PROPERTY LINE - PRIVASTIC WELL PUBLIC DOMESTIC WELL l <br /> INTENDED TYPE OF WELL CONSTRUCTION SP <br /> Industrial " Cable Tool Dia. of Well Excavation ECIFICATIONS <br /> 'IF- Domestic/private �_ Drilled <br /> Domestic/public Driven Dia, of Well Casing <br /> Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> Other Other Information <br /> Geophysical Surface Seal installed BY: <br /> PUMP INSTALLATION: Contractor <br /> A <br /> ;Type of Pump <br /> H.P. <br />'PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: L7 State Work Done <br /> P E&TRUCTION OF. Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 WI <br />'RIOR TO GROU AND F PE CrION LL CALL FORA GROUT INSPECTION <br /> SIGNED - <br /> TITLE <br /> �DRAV PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> P�P LICATION ACCEPTED BY DATE <br /> k�DDITIONAL COMMENTS: <br /> + <br /> PHASE II GROUT INSPECTION PHASE IIIITIN& INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY <br /> DATE U- /c, <br /> E H 1426 . Rev. 1-74 <br /> i-74 9M <br />