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z <br /> 'i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_OT;OFFICE USE: Vl"�1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicationiie hereby shade toithe 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 Gam[ r CENSUS TRACT . <br /> Owner's Name} Phone <br /> Address I <br /> City ' <br /> Contractor's Name r License # t--�Phone <br /> let (4 <br /> TYPE OF WORK (Check) NEW WELL -/-7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION /j <br /> PUMP INSTALLATION/PUMP REPAIR-/7 PUMP REPLACEMENT %f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> P`ROPERTY}.LINE PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia, of Well Casing <br /> omestic/public Driven Gauge of Casing <br /> Irrigation t Gravel 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 1Pump H.P. <br /> PUMP REPLACEMENT .— / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br />)ES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L 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 /> Lnformation is true to the-best.-of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GRO NG 'AND A INAL INSPECTION. <br /> SIGNED ! TITLE L <br /> DRAW PLOT PLAN ON REVERSE SID <br />?RASE I FOR DEPARTMENT USE ONLY t <br /> IPPLICATION ACCEPTED BY DATE — -� <br /> IDDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION P I AL INSPECTION <br />[NS1'ECT10N BY DATE INSPECTION' BY DATE C3"' <br /> E H 1426 Rev. 1-74 1,17 9i� <br />