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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1661 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 1 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No v�_/� <br /> F <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 workhereindescribed. This application is made in compliance with San Joaquin <br /> County Ordinance No. .186/2 and the Rules an Regulations of the San. ,Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION, ( f� f <br /> � CENSUS T•RACT . � <br /> Owner's-+ Name Phone � 3-7 W J <br /> Address City <br /> Contractor's Name t <br /> License # Phone <br /> V <br /> TYPE OF-WORK_(.Check).:-'NEW-WELL" --/-/-.' .DEEPEN-/_/-m.REGONDIT;ION•-,/f—DESTRUCTION/--7 -- <br /> PUMP INSTALLATION / / PUMP REPAIR,,/ '-I PUMP REPLACEMENT <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 OF WELL .`CONSTRUCTION SPECIFICATIONS _ <br /> Industrial i Cable Tool Dia, of`Well Excavation Q <br /> Domestic/private i Drilled Dia'. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal [ Other Other Information <br /> Geophysical _ Surface Seal Installed BY: <br /> PUMP INSTALLATION: <br /> Contractor 6�le56 <br /> Type of Pump i E H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP .REPAIR: / / State Work Donee <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 wel,l;constructi.on. 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 t the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTIN FINL�L� N.SP.ECT.IO.N.. Y.._. <br /> �.,. . <br /> SIGNED <br /> --r­—(DRAW PL _ TITLE <br /> OT PLAN ON-'REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I 5 <br /> APPLICATION ACCEPTED BY DATE d` �7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASE/jjI/FI3AL INSPECTION } <br /> INSPECTION BY DATE I1SPECTION BY DATE 7/ <br /> r� l <br /> E H 1426 Rev. - I-74 b17.7 <br />