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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP: 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 Health District. for a permit to cons tI,uct <br /> and/or inetall 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 D ENSUS TRACT,: <br /> Owner's Name <br /> Phone <br /> Address ,S ' Cit <br /> Contractor's Name License 1� ` one�3 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP -INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK J SEWER LINES j PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -PRIVA'TF DOMESTIC WF,LL &�,66 yPUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation C <br /> Domestic/private Ybrilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ravel Pack Depth of Grout Seal S4 P <br /> _ Cathodic Protection ?'PRotaryType of Grout <br /> Disposal `` _ Other Other Information <br /> Geophysical _ Surface Seal' Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - - H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR: . / / State Work Done--: , . <br /> DES-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, 1 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 F NAL INSPECTION. 1 <br /> SIGNED TITLE <br /> 76 (DRAW PLOT PLAN ON REVERSE SIDE)- <br /> FOR <br /> IDE)FOR DEPARTMENT USE ONLY f <br /> PHASE I <br /> APPLICATION ACCEPTED BY .4 !��zen-40-1 n� DATE <br /> ADDITIONAL COMMENTS: _ or <br /> P S II GROUT INSPEC ION PHA IIT/FINAL INSPECTION <br /> INSPECTION BY DATE �� INSPECTION BY DATE . <br /> E H 1426 Rev- 1-74 <br /> ,�% _ <br />