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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> ; •r FOR(OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> E <br /> f 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. <br /> This Joaqv <br /> County Ordinance No. 1862 and the Rules and Regulations toonthe SSaaneJ aquinin copLocaleHealthwithSan District. <br /> JOB ADDRESS/LOCATION <br /> ENSUS TRACT <br /> Owne'r's Name <br /> Phone <br /> Address <br /> City: <br /> Contractor's NameCKK�Z� Licene <br /> 1\t-16LA _ Phone Sx�7 <br /> TYPE OF WORK (Check): NEW WELL iZ7- <br /> EEPEN /_� RECONDITION /-7 DESTRUCTION /'? <br /> PUMP INSTALLATION / / PUMP REPAIR 1-7—Pump REPLACEMENT <br /> Other <br />} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVA <br /> IENDED USTE DOMESTIC WELL PUBLIC DOMESTIC WELT, <br /> i NTE TYPE OF WELL <br /> CON STRUCTYON SPECIFICATIONS <br /> industrial ��_.Tool Dia. of Well Excavation <br /> mastic/private Drilled Dia. of Well Casin <br /> �_-- Domestic/public Driven Gauge of Casing $ <br /> Irrigation Gravel Pack Depth of Grout kal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br />� Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-,,.REPAIR —.S tote;-Work�Done� <br /> ES 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 f MY knowledge and belief. I WILL CALL FOR A GR UT INSPECTION <br /> PRIOR TO ROU iNG FINAL INS CT ION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE ' <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BYPHASE III FINAL INSPECTION- <br /> DATE 3 7 INSPECTION BY DATE <br />�^ E H -1426 Rev. 1-74 <br />