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r <br /> i <br />' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT OFFICE USE: _ 31,101 E. Hazelton Ave. ,: Stockton, Calif. <br /> ' Telephone: (209) -466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.]Z-/fy� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t (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. 1$62 .ard the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address 9City n <br /> Contractor's Name 10 License # Q/ Phone <br /> 4Q <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/�/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR)9 PUMP REPLACEMENT 1_7 <br /> 0 then l / / <br /> DISTANCE TO NEAREST: SEPTICFTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC_WELL PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELT -� r ' �" '� CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. .of. Well. Excavation <br /> Domestic/private f Drilled Dia-. ',ofkWeIlWasing <br /> Domestic/public k Driven Gauge~ of Casing <br /> Irrigation Gravel Pack Depth.,of- Grout� geal,.� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I Other j,,Other Information <br /> Geophysical Surface Seal Installed By: - <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Y Type %f Pump H.P. - <br /> PUMP <br /> .P.PUMP REPLACEMENT: / / +hate Work Done <br /> F <br /> PUMP REPAIR: N State Work Done ,d <br /> DESTRUCTION OF WELL: Well�tiameter Approximate Depth <br /> Describe Material and' Procedure, <br /> ' I hereby agree to comply with all laws and regulatioh's 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 /> t PRIOR TO 0 TING ,AN,D,.A F NAL NSPECT N. <br /> SIGNED TITLE <br /> # (DRAW PLOT PLAN ON REVERSE SID ) .� <br /> E FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II SPtCTION APW04I/FIFA INSPECT ON <br /> INSPECTION BY ATE INSPECTION DATE <br /> M <br /> E H 1426 Rev. . 1-74 <br />