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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �-, THIS PERMIT EXPIRES 1 .:YEAR FROM DATE ISSUED Date Issued 29 <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 /> JOB ADDRESS/LOCATION ` <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address City �[�t'7 <br /> Contractor's Name �[ License # / <br /> honed <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/-/ RECONDITION _/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / j PUMP REPLACEMENT /7 <br /> Other / / '�` ��:�z` a � i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- PIT PRIVY <br /> SEWAGE:D:ISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> -" 1v -; .. . <br /> PROP.ERTY'-.L•INE­-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 Drilled Dia, of Well Casings <br /> Domestic/public Driven Gauge of-Casing Q <br /> Irrigation Gravel Pack Depth of".Grout Seal <br /> Cathodic Protection RotaryType 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 /> PUMP .REPAIR: <br /> kdC State Work Done <br /> DESTRUCTION 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 putting thewell in use.. The above <br /> information true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G.R UTING F-INAZ NSPECTION. <br /> SIGNED TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SID ) C <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY U" DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G I SP C IO PHASE I I/FIN INSP CTION i <br /> INSPECTION BY ATE INSPECTION BYG,/ DATF16-2 7 <br /> E H 1426 Rev. - I-74_ ._ nli7 2M <br />