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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR_OFF;C,E USE: 1601 E. Hazelton Ave. , Stockton, Calif. ,T <br /> Telephone: -<2093 466-6781 <br /> ` #r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT s Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �X <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 S Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION av (.� CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License # � hone i <br /> IL <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION / / DESTRUCTION /-7 T1 <br /> ' PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT 1-7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIO . <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 to--Xotary 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 <br /> f <br /> PUMP ,REPAIR: / / State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with allM` s 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 Joaqu cal HeaAabov <br /> ict a <br /> WELL DRILLERS REPORT of the well and notify them before putting the w 1 in se. "Tinformation is tr a the best o£ mynowledge and belief. I WILL ALL FO GROUION <br /> PRIOR TO GROUTIN A FINAL INSPE N. <br /> SIGNED TITLE <br /> DRAW ' T PL <br /> PLON RE ELISE SIDE) <br /> FOR DEPARTMIWT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � C�-- <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE II / INAL INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY <br /> DATE <br /> -Gt •. 2M <br /> E H 1426 Rev. 1- <br />