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v y SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> POE iOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67-81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No�T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ! <br /> Application is hereby made to the San Joaquin .Loca1 Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquini. <br /> County Ordinance No. 1862 and the Rules and Regulations of -the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION • .vfa . - r CENSUS TRACT <br /> Owner's Name Phone <br /> Address �,l City <br /> k <br /> Contractor t s Name .,�... License # / j 7z_C_Phone <br /> t ' <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN -/ RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /L� PUMP REPLACEMENT <br /> Other I 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER_ LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <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/privatet ' Drilled DiA. of Well Casing <br /> Domestic/public"` Driven Gauge .of Casing <br /> X Irrigation Gravel"Pack Depth of Grout Seal <br /> j 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 /> a <br /> PUMP :REPAIR: / State Work Done r <br /> ,RE&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 /> information is true to the-best ofmy . wle and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GR UTING AN A FINAL I 0 <br /> SIGNED TITLE r p <br /> 3WjgDPLOT PLAN ON SEVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> t PHASE II GROUT INSPECTION PHAS I I NAL INS PECTION <br /> G INSPECTION BY DATE INSPECTION $Y DATE ? <br /> - � E H 1426 Rev. 1-74 1-74 2M <br />