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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> rn (Complete In Triplicate) <br /> Application is h4ieby 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 /> bounty Ordinance No.' 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />' SOB ADDRESS/LOCATION ` J CENSUS TRACT <br /> Owner's Name ` a Phone <br /> Address'-- a qS Gey .l� City <br /> Contractor's Namei _Z <br /> ,,,,,. .,.._ —......._. Licenae � �di3-fl� ?hone �� � <br /> F <br /> _ ft <br /> 3 <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN '/? RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /X7 PUMP REPAIR /7 PUMP REPLACEMENT f <br /> Other <br /> 3 <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 ICable Tool Dia. of Well Excavation <br /> Domestic/private J Drilled Dia. of Well Casing <br /> Domestic/public . ._.. Driven Gauge of Casing <br /> IrrigationGravel 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: °.4 <br /> Contractor .•� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP `.REPAIR: /_' State Work Done <br /> ES;TRUCTION OF 'WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i + <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 /> i <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 puttingthewell 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 GROUT A FI NSP CTION. <br /> SIGNED r TITLE <br /> Sj DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIILFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> } E H 1426 f <br /> � Rev. 1-74 1-74 2M ' <br />