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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR-OFFICE USE; ' / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION � <br /> CENSUS TRACT <br /> Owner's Name 1 <br /> - Phone y y— <br /> Address <br /> City sro/o ?` <br /> Contractor's Name L� _License # <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR 0 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 /> Industrial Cable Tool Dia. of Well Excavation r <br /> Domestic/private Drilled Dia. of Well Casing T <br /> Irrigation <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> DisCathodic Protection Rotary Type of Grout <br /> Geophysical <br /> Other Other Information <br /> Geophhysiysi cal Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: j& State Work Done Q <br /> DESTRUCTION OF WELL: 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 we11 `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 C FOR A GR UT INSPECTION <br />'RIOR ROUTING AN A FI SPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br />?RASE I - <br /> FOR DEPARTMENT USE ONLY , <br /> APPLICATION ACCEPTED BY DATE 7� <br /> LDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .; , DATEI <br /> '1 _ . <br /> E H 1426 Rev. 1-74 -- 1177: <br />