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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 /> y <br /> 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 /> t and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> sl <br /> Owner's Name P 11f Phone ( <br /> Address -- `�!'_ •--- ---.__.__.,, ,..,...__. City LC /f.?_ <br /> Contractor's Name I� T Q License # ° i? Phone <br /> I�. <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN /_/ RECONDITION /-7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / 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 - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation G <br /> Domestic/private, Drilled Dia. of Well Casing <br /> 4 Domestic/public _ Driven 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ]�/ State Work Done <br /> ? PUMP '.REPAIR: / / State Work Done <br /> 5 <br /> DESTRUCTION 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 istrict <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 toilthe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ,PRIOR TO G ING AND A F AL INSPECTION. <br /> SIGNED ETITLE <br /> iN (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY " tee. DATE ^`�-,�S--7 , <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GR UT INSPECTION--, PHA§ I ,I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATEW <br /> d� <br /> 1f7 _ ' 2M <br /> E H 1426 Rev. 1-74 <br />