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.0 _ ,9`�' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.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 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local 11ealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin; <br /> I County Ordinance No. 1862 and tAp RulesandRegulations of the Sat: Joaquin Local Health District. <br /> A/ 7 00 <br /> JOB ADDRESS/LOCATION AZ CENSUS TRACT <br /> Owner's Name Phone <br /> 14 Address 9 <br /> City ,- <br /> Contractor's <br /> ity .Contractor's NameJ� �!'/1/J LicensePhone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /� RECONDITION /_7 DESTRUCTION f_7 <br /> _. PUMP INSTALLATION/L�::j P REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK Ze ej SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELT, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool, Dia. of Well. Excavation � <br /> [sfiomestic/private Drilled Dia. of Well Casing � ! <br /> Domestic/public 'Driven Gauge of Casing 1.7 <br /> Irrigation Gravel Pack Depth of Grout Seal 41 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed -By: <br /> PUMP INSTALLATION: Contractor , /j/ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPATR: / / State Work Done <br /> IIESTRUCTION 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 GRO I AND A FINAL I P ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 'p�2 0 -7 <br /> ADDITIONAL COMMENTS: .— <br /> PHASE I '11GOUT INSPECTION PHA U FINAL INSPECTIO <br /> INSPECTION BY DATE 2 (� INSPECTION BY DATE d / <br /> 1/ <br /> Rev. 1-74 ` i <br />_ 2M <br /> E H 1426 <br />