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�0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$.rOFFICE USE: 1601 E. Hazelton Ave. , Stockton.r 'Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 4R PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEISSUEDDate Issued 2;4y/?� <br /> (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 CENSUS TRACT <br /> owner's Name c� r� <br /> Phone J o <br /> Address 471 rCity <br /> Contractor's NameLicense Phone <br /> TYPE'OF WORK (Check) : NEW WELL )V"*DEEPEN -/? RE.CONDITION /? DESTRUCTION /_7PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT f <br /> Other / ; <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 Og WELL CONSTRUCTION SPECIFICATIONS <br /> F <br /> In Cable Tool Dia. of Well- Excavation m <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 <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> L PUMP REPLACEMENT: <br />.. / IT State Work Done <br /> y <br /> PUMP `REPAIR: /_7 State Work Done i <br /> ES•TRUCTION 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 A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT. USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIx FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> 1 E H 1426 Rev. 1-74 1 ,7 <br />