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SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. , <br /> Telephone: (209) 466-6781 Cj p� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS. PERMIT EXPIRES71 YEAR FROM DATE ISSUED Date Issued 7J. <br /> 4 (Complete In Triplicate) <br /> Applicatton..is Aereby made tothe San Joaquin Local Health District for a permit to--cp atruct <br /> and/or installthe work herein described. This application is made in complianee .with San Joaquin <br /> County.,Ordinance No: 1862 and the Rules and gulations of the Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .j ��� � CENSUS TRACT <br /> Owner's Named <br /> Phone <br /> Address f 3 City �- <br /> Contractor's Named License ���' Phony 4.4 a- ]? <br /> X <br /> TYPE OF WORK (Check): NEW WELL -4 DEEPEN /_ RECONDITION /�T DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST': SEPTIC TANK , � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHEg <br /> PROPERTY-LINE PRIVATE DOMESTIC WELL PUBLIC' DOMESTIC WELL <br /> INTENDED 'USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' U�, <br /> Indus trial <br /> Cable Tool Dia, of Well Excavation f'.I <br /> `Domestic/private , L—Drilled Dia, of Well Casing <br /> 'Domeptic/publit' Driven Gauge of Casing Z, <br /> Irrigation-x t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 11--Rotary Type of Grout <br /> Disposal*, r i Other Other Information <br /> - <br />—Geophysical � T Surface Seal Installed B <br /> PUMP INSTALLATION: •, Contractor <br /> Type of <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP iiEPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Di4meter Approximate Depth ; <br /> Describe Material a6d Procedure <br /> f <br /> I hereby agree ,.to comply with all 'laws and regulations of the San Joaquin Local'Health bia <br /> triet . <br /> and the State of California pertaining to or regulating well•construction. Within FIFTEEN .DAYS <br /> after completion of my work ona 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 FORA GROUT INSPECTION a <br /> PRIOR TO RQ ING AND A F AL INSPECTION. <br /> SIGNED' TITLE i. <br /> DRAW PLOT PLAN ON REVERSE SIDE) . ; <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ° PHASE 'II GROUT .INSPE TION PHASE fI /FINAL INSPECT OA <br /> i <br /> INSPECTION BY DATE INSPECTION BY DATE. <br /> zr- <br /> 1/1.7. 2ND <br /> E H X1426 Rev. 1-74 <br /> . �� ' w <br />