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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO1 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 /� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No?��/ r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date .Issued3- <br /> (Complete In Triplicate) <br /> Application is Aereb}r made totlf <br /> ,,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 N6.. 1862 an& the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , CENSUS TRACT <br /> Owner's Name Phone ', <br /> Address 4 City 14 <br /> s <br /> Contractor's Name License # daPhone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION_ /_7 DESTRUCTION /_7 4 <br /> PUMP INSTALLATION / / PUMP -REPAIR / / PUMP REPLACEMENT <br /> Other. /../ <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 -9 Cable Tool Dia, of Well Excavation <br /> Domestic/private :1 Drilled Dia. of Well Casing ' , <br /> Domestic/public ± Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal` <br /> Cathodic Protection ., Rotary Type' of Grout <br /> Disposal ;1 Other 'Other Information <br /> ` ... <br />-Geophysical - _ .. -_ <br /> _." __-Surface <br /> Se-al-Installed By: . . .--- <br /> PUMP INSTALLATION: Contractor =, <br /> Type of Pump - H.P. -` <br /> F r <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: _ 1 te - <br /> / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health bistrict <br /> and the State of California pertaining to or regulating well construction.. Within FIFTEEN DAYS a <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 GRO TING AND A FINAL I NSP CTIO14. <br /> SIGNED TITLE i <br /> (DRAV PLOT PLAN ON REVERSE SIDE) a Q <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY DATE _{7 !. <br /> E H 1426 Rev. 1-74 1.177 2M 4 <br />