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_ b_ i JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: lam'' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued +?7 <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 a plication is made in compliance with San Joaquin <br /> County Ordinance No. -1862 and the Rules a tion of the San Joaquin Local Health District, <br /> r ,�.. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone /a /0 / <br /> Address _ �j _57 Ci i <br /> Contractor's Name License 16 a�;'�Phone "P'g <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /7 RECONDITIO / / DESTRUCTION /7 - .b <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 OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL l\ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/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 By: <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump T H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Do <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth " (T1 <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED _ ,,J ,�� TITLE ��e <br /> (DRAW PLOT PLAN ON REVERSE SIDE) � <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I l/ <br /> APPLICATION ACCEPTED BY DATE 25 <br /> ADDITIONAL COMMENTS: <br /> PHASE II..,GROUT INSPVeTION PHASE II/FI AL IN PECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> � r <br /> 1177 <br /> E H 1426 Rev. 1-74 a <br />