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{ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FO£x'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 /,g- <br /> (Complete <br /> ,g;(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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .4,eZd�: ,/ r CENSUS TRACT <br /> Owner's NamePhone <br /> Address 2ZZ2 UZ City <br /> Contractor's Name . License _Ej5&XPhone <br /> TYPE OF WORM (Check): NEW WELL L7 DEEPEN '/lRECONDITION /7 DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR -/-7-pump REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p� <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1.1 <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS \n <br /> Irtaustrial Cable Tool Dia. of Well Excavation' <br /> vmestic/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 <br /> Type of Pump 4 <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 DEPARTMENT USE ONLY --- ^^ <br /> PHASE I zj <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTZON <br /> INSPECTION BY DATE INSPECTION BY DATEZ'// <br /> E H 1426 Rev. .1-74 -2M <br />