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a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFpOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 �7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,% <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> (Complete In Triplicate) <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 No. 1862 and the Rut and Regulatio of the San Joaquin Local Health District. <br /> i /q <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's'Name Phone <br /> Address [ "�� City ..., <br /> Contractor's Name License # 4 Phone <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN /_/ RECONDITION / / DESTRUCTION 1-7 <br /> ! PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT '���F-f <br /> ;E 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 QI <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled " Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ll <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 B <br /> PUMP INSTALLATION: Conttactot ":� & <br />` T.ypeaf Pump.. _ _ - H.P, <br /> PUMP REPLACEMENT: . ; State Work Dane <br /> PUMP .REPAIR: /, / State Work Done <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 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 the best of my-knowledge and belief. I WILL CAIVFOR A GROUT INSPECTION <br /> PRIOR TO OUTING FI INS CT ION. <br /> SIGNED TITLE <br /> ' DRAW'PL'T PLAN 'ON REVERSE SIFOR DEPARTMENT UDE)--- - <br /> PHASE T USE ONLY <br /> APPLICATION ACCEPTED BY DATE { <br /> ADDITIONAL ,COMMENTS: <br /> PHASE TI ROUT INSPECTION PHAS I/FINAL INSPECTION <br /> INSPECTION 'BY DATE INSPECTION BY DATE j_Zj_7-.!r <br /> E H 1426 Rev. 1-74 3/76 2M. <br />