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�7 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr,:OFFI'C:s USE: 1601 E. Hazelton Ave. Stockton,Stockton, Calif. <br /> 1 <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 IssuedJ6'. ; <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> s and/or install the work;therein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18162 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION � 2 S ' <br /> Owner's Name ' :'� Phone., <br /> Address .. City <br /> Contractor's Name - License # -Phone <br /> TYPE .OF WORK (Check): 'NEW WELLDEEPEN '/7 RECONDITION /7 DESTRUCTION I% <br /> ':PUMP INSTZTiON ] I PUMP REPAIR'/_T Pte. REPLACEMENT 17 <br /> .Other <br /> ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DIST AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial i , Cable Tool Dia. of Well Excavation 7 <br /> Domestic/private Drilled Dia. of Well Casing <br /> k. pin <br /> Domestic/public Driven -Gauge of Casing <br /> Irrigation _ ravel Pack Depth of Grout Seal <br /> Cathodic Protection r Rotary Type of Grout __- <br /> Disposal Other Other Information ' ' <br /> Geophysical II Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> , Type of Pump A.P. <br /> F • <br /> PUMP REPLACEMENT: . <br /> J / State Work Done <br /> PUMP 'REPAIR: State Work Done <br /> Ii-— <br /> 2ES-TRUC_T_ION OF WELL: ; iWell Diameter Approximate Depth <br /> Describe Material ..and Procedure. <br /> I hereby agree to comply with all Laws and regulations of the San.3oaqui L-Local-Hea_lth�Distr-ict. . <br /> �.:., <br /> and=the-YStam of`Califoriria-p-e-�A_1ning-to of regulating we11''canstruct��on. Within FIFTEEN DAYS <br /> after •completion of:Fmy.work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o�€ the well and notify them before putting the..well. in.use.... .The above <br /> ' information is true tothe.best of my..kn wledge and belief. I WILL L OR A GRO INSPECTION <br /> PRIOR TO GRO11TING ANDA FINAL INSPECTI <br /> iSIGNED TITLE <br /> (DRAW PLOT LAN ON REVERSE SIDE <br /> E FOR DEPARTMENT USE ONLY <br /> PHASE I I . DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> P SE I-a1GROUT INSPECTION PHASE-III/FINAL INSPEC ION <br /> INSPECTION BDATEINSPECTION BY <br /> E'H 1426 Rev. -,_=.74 <br />