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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466 .6781 77- 661 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued s�a <br /> (Complete In. Triplicate) }, <br /> Application is hereby made to the San Joaquin Local Health District fora 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 D O CENSUS TRACT <br /> Owner's Name Phone <br /> Address / City <br /> Contractor's Name ��> <br /> License . ��� Phone - Q <br /> # I <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN 17 RECONDITION /'7 DESTRUCTION /7 <br /> PUMP INSTALLATION-NY-7 PUMP REPAIR/?PUMP REPLACEMENT <br /> Other %// <br /> j <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> AP 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 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 j <br /> Cathodic Protection Rotary Type of Grout ` <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'By: <br /> I <br />;PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. j <br /> I <br />-PUMP REPLACEMENT.- / "!/ State Work Done <br />•PUMP ,.REPAIR: / State Work Done <br /> k <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> ,.. <br /> Describe Material and Procedure j <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''construct. on-., Within FIFTEEN DAYS <br /> after completion of my work on anew well,. I will furnish the .San Joaquin. Locai- Health District al <br />+WELL DRILLERS REPORT of the. well, and,notify them; before putting.-thee-well, in.use.... .The above <br /> information is true to the•best.of. my..knowledge and belief. I WILL CALL FOR A ,GROt]T. INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR 'DEPARTMENT USE" ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE'[-2?._7 7 <br /> ADDITIONAL COMMENTSs <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY. DATE <br /> E H 1426 Rev. 1-74 !x/75 2M <br />