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FOE.OFCE SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FIUSE: 1601 E. Hazelton Ave. <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a pbrmit to construct <br /> i <br /> and/or install the work herein described. This application is made in compliance with <br /> County Ordinance No. 1862 and. the Rules and Regulations of the San Joaquin Local- Health District. <br /> JOB ADDRESS/LOCATION f <br /> CENSUS TRACT <br /> Owner's Name <br /> © Phone $�$ `�yf� <br /> Address S� MOLO <br /> �� City <br /> Contractor's Name °-- <br /> �" License # & Phone g - v 7 <br /> TYPE OF WORK {Check}: NEW WELL/? DEEPEN '/-7 RECONDITION L7 DESTRUCTION /% <br /> PUMP ,INSTALLATION / / PUMP REPAIRR -j PUMP REPLACEMENT /% <br /> ­Other <br /> — <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE --TYPPRIVATE DOMESTIC WELT,' PUBLIC DOMESTIC WELL <br /> INTENDED USE E OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool \ <br /> Domestic/private Drilled Dia. of We11 Excavation <br /> _ Domestic '� V - _ Dia._of Wel3._Casing_' \ <br /> /Public' Driven � - . µ 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 ---�---- <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. <br /> PUMP REPLACEMENT / / State Work Done Fl <br /> PUMP '.REPAIR: State Werk Done' _ _r <br /> O U�n <br /> DESTRUCTION OF WELL: Well Diameter 4 <br /> Describe Material and Procedure Approximate Depth <br /> ----_ <br /> l <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 /> TELL DRILLERS. REPORT of the well and notify them before putting the..wel,l. in-use.. . The above <br /> Information is true to-the-best of my.knowledge and belief. I WILL CALL F R A 'GROUT INSPECTION <br />'RIOR TO G TING AND F NAL INSPECTION. <br />>IGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br />'HASE I r FOR DEPARTMENT USE ONLY <br />►PPLICATION' ACCEPTED BY �J <br />►DDITIONAL COMMENTS: DATE <br /> NSPECTION BY <br /> PHASE II GROUT NSPECTION PHA I N INSPECTIO <br /> DATE INSPECTION BY <br /> E <br /> E H 1.426 Rev. 1-74 <br />