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F <br /> �,) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7F0-r1--OFFICE USE: Jed 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �'� <br /> 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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION v , CENSUS TRACT <br /> Owner's Name Phone <br /> Address �Q CityS`er4 /N <br /> Contractor's Name License �� 1Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTAL ATION X PUMP REPAIR / / PUMP REPLACEMENT /7 I <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 /> Industrial X 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 /> Pj`MP INSTALLATION: Contractor { � <br /> r Type of Pump — �CY►'� 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 /> r <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 j <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 GROTAT INSPECTION ' <br /> PRIOR TO G.ROTING 40D A FIN INSPECTION. <br /> SIGNED TITLE :I <br /> (DfWW PLOT PLAN ON REVERSE SIDE) j <br /> LFORDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE "Z 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF,, YII/FIFAL INSPECTION <br /> INSPECTION BY DATE Py INSPECTION B DATE/ ' <br /> 1 � <br /> E H 1426 Rev. 1-74 is 0 iAP 117 1 <br />