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_ SAN JOAQUIN LOCAL HEALTH DISTRICT Lo�'`S <br /> FOE OFFICE USE:' r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (il-el 7A, <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 Joaqu n <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distric . <br /> JOB ADDRESS/LOCATION r / CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License # & hone .2 <br /> . . i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / <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 /> I-vkrustria,l 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 otary 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 /> PUMP .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 FIFTEENN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting t in use. The above i <br /> information s true to the best of- my knowledge and belief. I WICL CALL FOR A `G T NSPECT <br /> PRIOR TO TING AND A FIN NSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN 'ON REVK.tSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. . 1-74 <br /> 3/76 2N <br />