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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFIESE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r <br /> Telephone :p (209) 466-6781 a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> j (Complete In Triplicate) j <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No1/9vrsl <br /> 2 and t e Rules andl�e ulations o S n oaqu'n Local Health District <br /> JOB ADDRESS/LOCATIO / US TRACT <br /> Owner's Name Phone <br /> � �� -- <br /> Address � f 'd City <br /> Contractor's -Nanke <br /> � ;� License Phone <br /> f TYPE OF WORK (Check) : „ NEW WELL / / DEEPEN _/ RECONDITION / / DESTRUCTION /-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 <br /> f.��omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary 'Type of Grout <br /> Disposal Other <br /> Other Information i <br /> Geophysical Surface Seal 1 nst-A lled By: <br /> _. <br /> PUMP INSTALLATION: <br /> Contractor ,�� <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP :REPAIR: <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth j <br /> Describe Material and Procedure <br /> I hereby agree to comply' wi.th all laws and regulations of the San Joaquin Local Health District <br /> and the State of Califoriiia 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 aj <br /> WELL DRILLERS REPORT of the well and notifythem before <br /> putting the well in use.. . The above 4 <br /> information true to the best of. my no edge a belief. TWILL CALL F A GROUT INSPECTION r <br /> PRIOR TO G ING AND F.'NAT, NSPE UN <br /> SIGNED /f TITLE A <br /> DRAW PLOT LAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTED BY bM1 <br /> ADDITIONAL COMMENTS: <br /> DATE <br /> PHASE II GROUT INSPECTION <br /> PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY72Z- DATE <br /> E H 1426 Rev. . 1-74 ��77 2M <br />