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JOAQUTN LOCAL HEALTH DISTRICT <br /> FQBrOFFICE USE: 1601,. ,;. Hazelton Ave. , Stockton, Cal. <br /> Telephone: (209) 466-6781 VW <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI rmJWA17 <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued 6 <br /> ' (Complete In Triplicate) 7 <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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4 p <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> I Contractor's Name License # <br /> t Phone -,2? <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN `/-7 RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION /R—PUMP REPAIR PUMP REPLACEMENT f7 <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 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 j <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. / <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP 'REPAIR: /7 State Work Done <br /> ES-T-RUCTION 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 GROU G AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) '" <br /> FOR DEPARTMENT USE ONLY $ <br /> PHASE 'I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> PHASE II INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE y <br /> E H 1426 Rev. 1-74 <br />