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�c nt // SAN JOA.QUIN LOCAL HEALTH DISTRICT �. <br /> FORA FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Ts f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ,p (Complete in Triplicate). <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 1 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 /> k <br /> i JOE ADDRESS/LOCAT tJN CENSUS TRACT <br /> A Phone <br /> pwnerIs Name <br /> Address "` City Imo. <br /> ..� <br /> f <br /> Contractor's Name - License # Phone " �r <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN %/ RECONDITION /-7 DESTRUCTION <br /> PUMPIINSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> f Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 1, Irrigation Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection 9 Rotary Type of Grout. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> I <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump 44 4 4 H.P. y <br /> PUMP REPLACEMENT:' ` / / State Work Done <br /> I PUMP 'REPAIR: / State Work Done ' _U „�,� ��- - � A, <br /> s <br /> pE5 TRUCTION 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 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 /> f information is true to the best of�myi=PLAN <br /> belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OU ING AN A FINAL IN SIGNED ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i DATE - " r <br /> ADDITIONAL COMMENTS: / <br /> i PHASE II GROUT INSPECTION PHASE III IN INSPECTION <br /> t INSPECTION BY i DATE - INSPECTION BY ssE DATE rl <br /> it <br /> `"`Q 74 2M <br /> ~E H 1426 Rev. 1-74 r_ c <br />