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SAN JOAQUIN .LOCAL HEALTH DISTRICT y { <br /> FOE '6�ICE 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 5__ J7�1 <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 CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name r df License-0 Pizone <br /> f- <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN / / RECONDITION /DESTRUCTION /-7- <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Al4 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 'jjn2-j�CESSPOOL/SEEPAGE PIT _ OTHER .r <br /> PROPERTY LINE, -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial moble Tool Dia, of Well Excavation <br /> L�bmestic/private Drilled Dia. of Well Casing "-` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 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 /> - - - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ? <br /> PUMP REPLACEMENT: / / State Work Done <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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROJWING D A FINAL INSPECTION. <br /> SIGNED t <br /> _TITLE _ <br /> {DRA PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE ^ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE -III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 o,�]] _ 2M <br />