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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: !f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;h R j' ; <br /> VF 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. 11862 and the Rules and. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / _l_ �+ CENSUS TRACT <br /> Owner's•Name _ '� -- . .,. Phone <br /> Addre®s City <br /> Contractor's Name_ License # Phone <br /> TYPE OF WORK (Check).: NEW WELL /_7 DEEPEN '/7 RECONDITION /-T DESTRUCTION /7 <br /> PUMP INSTALLATION �� PUMP REPAIR /=J PUMP REPLACEMENT /7 <br /> Other / 7 <br /> : i <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 /> r Domestic/private Drilled Dia. of Well Casing 1, <br /> Domestic/public Driven Gauge of Casing "1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal , .6 Other Other Information <br /> p Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: + Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR; 17 State Work Done , <br /> ESTRUCTION 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 jo TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 111tt9 DATE 9 AW <br /> x <br /> E H 1426 Rev. 1-74 w, 1-74 2M -� <br />