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'ZAN JOAQUIN LOCAL HEALTH DISTRIC-- <br /> FOE OFFICE USE: 4 9 16,ft E. Hazelton Ave. , Stockton, C6..f. <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 Joaqui <br /> County Ordinance No. 1862 and the Rul and Regula of the San Joaquin Local Health District. <br /> JOB ADDRESS/LO ON e'% t'� CENSUS TRACT + <br /> Owner's Name. Phone � � <br /> Address City <br /> Contractor's Name License/� 3Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_/_/ RECONDITI / / DESTRUCTION /7 <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 /> 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 \ <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 Don <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 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 GROUTING AND A FINAL INSPECTION. _ <br /> SIGNED 17 TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (�/ DATE <br /> APPLICATION ACCEPTED BY 'LT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I1,1/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY % =DATE <br /> 1fj7 <br /> E H 1426 Rev. 1-74 _ <br />