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SAN JOAQUIN LOCAL HE _ --.---_ <br /> FORtOFFICE USE: HEALTH DISTRICT <br /> 1'601 E. Hazelton Ave. , Stockton, Calif. <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 <br /> Application, is hereby made to the Safi Jn uin Local Health District for a permit to construct <br /> and/or install the-work herein described. This application made in compliance with San Joaquin <br /> County Ordinance No.�. 1862 and the Rules and Regulations of a San Joaqu Local Health District. <br /> JOB ADDRESS/LOCATION <br /> C SUS TRACT <br /> Owner's Name�� <br /> Address �. �` City f <br /> Contractor's Na // � °' •� <br /> "�' LiceZe Phone's "� 7 <br /> TYPE OF WORK Check)- a � r �DEPEN / 7 EW WEL/ RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REP3.ACEMEN F <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - <br /> INTPRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> ENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TIONS <br /> „�„� Industrial <br /> — able Tool Dia. of Well Excavation <br /> �, omestic/private Drilled <br /> Dia. of Well Casing a� <br /> Domestic/public Driven Gauge of Casing � <br /> Irrigation k Gravel Pack Depth of Grout Seal, <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " ] f <br /> Geophysical <br /> Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor ; <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ���•� <br /> L/ State Work Done <br /> PUMP :-REPAIR: .� <br /> /�'"`-State=Work-Done <br /> E&TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 AM4,A FINAL ILNkLECTION. <br /> SIGNED • <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -;toe � <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROAT INSPECTION ' <br /> INSPECTION BY PHASE III FINAL INSPECTION # <br /> DATE 7Sr INSPECTION. BY DATE <br /> E H 1426 Rev. 1-74 <br /> _ y_74 qu <br />