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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7W:OFFICE USE: 1601 E. Haxelton.Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � / <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued d�1 � <br /> I (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 CENSUS' TRACT <br /> J <br /> Owner's Name at Phone ' <br /> Address , City ' <br /> License Phone — <br /> Contractor's Name � <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INST TION J / PUMP REPAIR/� PUMP REPLACEMENT /7 <br /> r , Other �. — <br /> DISTANCE TON T: SEPTIC T SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL R'T <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 B <br /> PUMP INSTALLATION: Contractor <br /> Type :of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR: /X State Work Done t <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 ANDA FINAL INSPECTION. <br /> ' SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDRT <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAU. I 14EMAL INSPECTION <br /> INSPECTION BY DATE — INSPECTION BY ��^ DATE �j--: <br /> tt <br /> 4, <br /> ' 'E H 1426 Rev. 7-74 1i/7c� 9M <br />