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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THd PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to[ he 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 Re1qulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION % CENSUS TRACT <br /> Owner's Name � I �� Phone <br /> Address 7~' - City/� � -s <br /> Contractor's Name �. License #;LF`60'i Phone � <br /> t <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT &7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ___._SEWAGE_44 1SP.OSAL_F.IELD.,_____._•..._-_CESSPOOL/.SEEPAGE..PIT,_.-,._.__._..,..OTHER. <br /> PROPERTf_1INE = PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 'INTENDED' USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' <br /> Industrial 1 Cable Tool Dia. of Well' Ekbavation, <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation ! Gravel Pack Depth of Grout ..Seal___�._j <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal I Other Other Information t <br /> Geophysical Surface Seal Installed By,: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done„0 _c�,-u �.�.�.+ ✓`` f <br /> PUMP .REPAIR: / / State Work Done <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. 'The above <br /> information is true to best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING APP AL.T NSPE CTION. <br /> r <br /> SIGNED TITLE �'�r.,�.�.� .. �' . <br /> DRAW PL T PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />