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FOR SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rOFFTCE 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 FROMDATE ISSUED <br /> ,.. . Date Issued a-7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to c <br /> . and/or install onstxu 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 /> .FOB ADDRESS/LOCATION • <br /> CENSUS TRACT <br /> Owner's Name I <br /> Phone' <br /> Address' <br /> 4 City <br /> 5 <br /> Contractor's Name <br /> License IW Phone <br /> TYPE OF WORK (Check): NEW WELL I-T DEEP /7 RECONDITION / E <br /> A PU14P �INSTALLATION O PUMP REPAIR 1-7 PUMPREPLACI <br /> Other I// <br /> DISTANCE TO NEAREST: SEPTICITANK SEWE <br /> R LINES PIT PRIVY ��� . <br /> E SEWAGV DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIOT WELL <br /> ' INTENDED USE TYPE OF WELL LL <br /> IndustrialCONSTRUCTION SPECIFICATI <br /> Domestic/ ONS <br /> Cable Tool Dia. of Well Excavation <br /> private t �- Drilled Dia. of Well Casing <br /> Domestic./public ;F Driven <br /> Irrigation Gauge of Casing fI <br /> Gravel Pack Depth of Grout Seal { <br /> Cathodic Protection ,i Rotary Type of Grout <br /> 3 <br /> Disposal i i Other <br /> Geophysical _ Other Information <br /> Surface Seal Installed S ; <br /> PUMP INSTALLATION: <br /> Contrac. tovez <br /> Type of Pump <br /> _ H.P. �L <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP '.REPAIR: <br /> 17 State Work Done <br /> ES TRUCTION OF WELL: Well Diameter <br /> Describe Materialand Procedure Approximate Depth <br /> t <br /> I hereby agree to comply with!'a11 laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. <br /> after completion of my work ori a new well, I will fWithin FIFTEEN DAYS <br /> urnish 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 tot ,best of my.knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO G TING AND FI AL ,INSPECTI N. <br /> SIGNED <br /> TITL j <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE i r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE FIN INSPECTION <br /> INSPECTION $Y DATE INSPECTION BYj <br /> - . . .a DATE - g-7 r <br /> E H 1426 Rev. 1-74 <br />