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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fOp*;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issued <br /> {Complete In Triplicate) <br /> Application is he6by 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 Rules and Regulations Of. the San Joaquin Local Health District. 1 <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION ° ' -' <br /> Phone <br /> Owner's Name <br /> • - _f City ..�.. <br /> Address . <br /> Contractor's Name ' . _ /` License Phone <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION � PUMP REPAIR I 7 PUMP REPLACEMENT f7 <br /> Other i-1 <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 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 Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor ��-, ' ,' H.P. <br /> Type of Pump .... jl .►. <br /> PUMP REPLACEMENT; / / State Work Done <br /> } <br /> PUMP : AIR, State Work Done F �� <br /> ;V <br /> ES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply with all <br /> and the State of California pertaining to or regulating well construction. <br /> Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District 4 <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'knowled e• and' belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION.. � ' <br /> SIGNED - TL �. <br /> - {DRAW PLOT PLAN ON REVS SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE Z% %5 <br /> APPLICATION ACCEPTED BY " <br /> ADDITIONAL COMMENTS: p SE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE •' '121 <br /> INSPECTION BY _ DATE INSPECTION BY ra��----- <br /> 1-74 2M <br /> ^E H 1426 Rev. 1-74 <br />