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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 4'0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �10 <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 /> I JOB ADDRESS/LOCATION CENSUS TRACT-_ <br /> Owner's Name., J'u i Phone <br /> Address <br /> ! Contractor's Name <br /> ..� License Phone �� <br /> ik TYPE OF WORK (Check): NEW WELL /_ . DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 . <br /> PUMP INSTALLATION / I PUMP REPAIR f / PUMP REPLACEMENT I . <br /> r <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 Cable Tool.. Dia, of Well Excavation _ <br /> Domestic'/private F Drilled ' ` Dia. of Well Casing <br /> j Domestic/public r Driven f Gauge of Casing <br /> E al Irrigation. Gravel Pack Depth of Grout Se <br /> � U <br /> j Cathodic.''Protection 1 Rotary,a,, . Type of Grout \ <br /> ! Disposal "' i ;' i Other' Other Information <br /> . Geophysical r Surface Seal Installed By: <br /> PUMP INSTALLATION: T Contracto <br /> Type. of Pump H.P. <br /> I PUMP REPLACEMENT: % / i. State Work Done <br /> PUMP .REPAIR: / State Work Done' <br /> ( DESTRUCTION OF WELL: We1liDiameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complywith all laws and regulations of the San Joaquin Local Health District <br /> 1 and the .State of California pertaining to or regulating well•'construction. Within FIFTEEN DAYS <br /> after completion of my work on a uew'well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORTof the well and notify them before putting the well in use. The above <br /> information is true ito' the -"best of L my knowledge and belief. I WILL CALL FOR A GROUT :INSPECTION <br /> � PRIOR-TO G UTING%AND'A FINAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> I DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ( <br /> PHASE I r� ` - -7 <br /> APPLICATION ACCEPTED BY Ln.J DATE 'T <br /> ADDITIONAL COMMENTS: + <br /> PHASE II GROUT. INSPECTION pHASE,..IjA/FM8 INSPECTION <br /> INSPECTION BY ( DATE INSPECTION BY DATE <br /> t 177 _ ,2K <br /> E H 1426 Rev. 1-74 t'= . <br />