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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITermit No. 7S-h�37P <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. 18 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . <br /> CENSUS TRACT <br /> Owner's Name Phonerp <br /> Address City b <br /> Contractor's Name x License #�90 Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN/-7 RECONDITION L7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /? PUMP REPLACEMENT <br /> Other /Y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> P(—LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cagle 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 H.P. <br /> PUMP REPLACEMENT: /-State Work Done 01.4 �firy' <br /> PUMP 'REPAIR: /? State Work Done ,y <br /> &E—S-1 RUCTION 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 Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe- well in use.. The above <br /> information is true to the best of- my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GR(}UTING INSP CPION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHME_E FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br />} E H 1426 Rev. 1-74 <br /> 1-74 2M <br />