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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PflF OFFICE <br /> USE:. :. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 *AR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Isocal Health District for a permit to construct <br /> and/or knstall 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 /> JOB ADDRESS/LOCATION A L2 <br /> L 114112�� CENSUS TRACT <br /> Owner's Name _ Phone <br /> Address City <br /> Contractor's Name License �` `� cZL j <br /> — a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / J RECONDITION /—/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR J J PUMP REPLACEMENT <br /> Other / J — 01 <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 /> Domestic/private -- -xDrilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection V Rotary Type of Grout _1�n <br /> Disposal. Other, Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> _ - - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTME T USE ONLY <br /> PHASE I Z <br /> 'APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GRO T INSPECTION PHA§A FINAL. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE .2-r?-rJ <br /> E H 1426 Rev. - 1-74 6/77 <br />