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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FOR(OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> I 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 Joaquin ! <br /> County Ordinance No. 1862 and' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> ` Phone <br /> Address -- City <br /> I <br /> j <br /> Contractor's .Name License # . 41201— Phone <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN '17 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /77 PUMP REPAIR /� PUMP REPLACEMENT %f <br /> Other /_7 <br /> r <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 s <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> r Domestic/public it Driven Gauge of Casing <br /> Irrigation ^ Gravel Pack Depth of Grout Seal, <br /> Cathodic Protection A Rotary Type of Grout <br /> Disposal 1 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 /> f � <br /> PUMP,'.REPAIR: /? State Work Done _ <br /> t <br /> ES.'TRUCTION 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 I <br /> information is true to the-best' -of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION I <br /> PRIOR TO GROUTING AND A FINAL I14SPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN VECTION PHASE II RINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION, BY A, 77 <br /> DATE - — <br /> E H 1426 Rev. 1-74 1-74 9bt <br /> 1 <br />