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SAN JOAQUINJCAL HEALTH DISTRICT <br /> I� 'FO'6,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-,/- <br /> (Complete <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 In CENSUS TRACT <br /> t Owner's Name ' Phone <br /> Address city - <br /> Contractor's Name license Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/ RECONDITION / 7 DESTRUCTION /-T •. <br /> PUMP INSTALLATION J / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> r <br /> Other <br /> r 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 /> I dustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing rA <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation GG avel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed B , <br /> PUMP INSTALLATION: . 'Contractor ` <br /> Type of Pump <br /> PUMP REPLACEMENT: j / State Work Done <br /> PUMP ,REPAIR: / / State Work Done . <br /> f - <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 well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting.. the..well. in.use.... The above l <br /> information is true to'the•bes t .af- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A VINAL INSPECTION. . <br /> SIGNEDTITLE <br /> �DRAV PLOT PLAN ON REVERSE SIDEI) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE ' 7d <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PEgT4 III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2-2 33 7 <br /> t E H 1426 Rev. 1--74 - -- ^- �1T75 2M -- <br />