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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE 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 YEAR FROM DATE ISSUED Date Issued <br /> ? I (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 an"d the Rules and 'Regulations of the San Joaquin Local Health District. <br /> t JOB ADDRESS/LOCATION .J � CENSUS TRACT ' <br /> Owner's Name., • Phone <br /> iCity <br /> Address p <br /> t License hon0l3 � <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /-7- -7 <br /> -7 <br /> j PUMPIINSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT I� �J <br /> f Other <br /> DISTANCE TO °NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINQ.0 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (o <br /> Industrial t Cable Tool Dia, of Well. Excavation - <br /> Domestic/private , Drilled Dia. of Well Casing � � <br /> Domestic/public Driven Gauge of Casing <br /> r Irrigation Gravel Pack Depth of Grout Seal C7 <br /> I Cathodic Protection V Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> k <br /> c <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / /I State Work Done <br /> IDESiRUCTION OF WELL: Well Diameter Approximate Depth <br /> fi 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 <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 FI AL INSPECTION. <br /> TITLE <br /> SIGNED <br /> {DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> 1 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONALCOMMENTS: <br /> PHAS II G OUT INS CTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE <br /> 2M <br /> E-H. 1426 Rev. • 1-74 - <br />