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SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> FOE OFFICE USE: :1 O1 E. Hazelton Ave. , Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 181p and the Rules and Regulations -of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> ' JOB ADDRESS/LOC. ON Q <br /> owner's Name Phan.e <br /> r <br /> Address ! City <br /> ' <br /> Contractor's Name License /Z_>3 73hona ACZ�__ <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION / / DESTRUCTION f� <br /> PUMP INSTALLATION - / PUMP REPAIR PUMP REPLACEMENT <br /> F Other 1 / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE P'IT 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 /> k Geophysical Surface Seal InstAlled By: <br /> PUMP INSTALLATION-:. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - / / State Work Done <br /> PUMP7UFA_IR-._ t�ate Work Aone 0406 <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 'i <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 DAMS <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 /> PLAN 'ON REffRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> k APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; + <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIaN BY ^�.,.+ DATE INSPECTION BY i DATE <br /> wCOV76 W <br /> }� E R 1426 Rev. 3^. 74 <br />