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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OP,FICE USE. 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pe mit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date .Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local, Health District. <br /> JOB ADDRESS/LOCATION - Ce--50 CENSUS. TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contracto 's Name � �� /`yfD License �� Phonei-� <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /T <br /> AL <br /> PUMP INSTLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NFkREST: 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 <br /> ELL <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 /> Irrigation Gravel Pac'k '- 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 ( � �... �r�¢��, .T <br /> Type of Pump l� H.P. <br /> PUMP REPLACEMENT; /�/ State Work DoneJ <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 to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t DATE y' <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION P /FIN INSP CT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1f 77 ' 2M <br />