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' SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FORrOFFICE USE: 160 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 / <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 l�jl $ CENSUS TRACT <br /> Owner's Name, Phone 9sa- <br /> Address SIO L2� <br /> Contractor's Name _,I,_.� A �/ N (� �^ � <br /> l?.�_4,S�QLicense # o?7901t, Phone p <br /> TYPE OF WORK (Check): NEW WELL -/ DEEPEN`/_7 RECONDITION /7 DESTRUCTION /7PUMPI,INSTALLATION / I PUMP REPAIR f PUMP REPLACEMENT J f <br /> "� ��•� , , A , Other ,F+/ <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Gau a of Casin <br /> Irrigation 8= = - - <br /> � Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout E <br /> Disposal Other Other Information <br /> Geophysical <br /> _ Surface Seal Installed_B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> Em !REPAIR:` f State Work Done h 42 <br /> -- �- <br /> ES;TRUCTION 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-J.oaquin_Looal-Bealth-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 knowledg€' and belief: I WILL CALL FOR A LGROUT INSPECTION <br /> PRIOR TO GRO ING AND &EINAT, INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDiA ' <br /> PFOR DEPARTMENT USE ONLY <br /> HASE I `' �� �. r� <br /> APPLICATION ACCEPTED BY <br /> , DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 0 INSPECTION PHASE 4iI INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /2 <br /> � E H 1426 Rev. ""-74 1-74 2M <br /> 'r,, <br />