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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. (r` <br /> j Telephone : (209) 466--6781 <br /> APPLIC}}ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 � <br /> THIS PERMIT EXPIRES' l.YEAR FROM DATE ISSUED Date Issued //- <br /> 1 (Complete In Triplicate) 7l <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, ARWCENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> .3 City • $�3_3/�ES <br /> Contractor's Name <br /> ivo License � ' Phone <br /> z <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTAI ATION / / PUMP REPAIR / f PUMP REPLACEMENT f f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC :TANK r-f- SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD C SSPOOL/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 Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation F1 Gravel Pack Depth of Grout Seal _ f <br /> Cathodic Protection t Rotary Type of Grout. ( .� <br /> Disposal fir Other.. . Other Information `tel <br /> Geophysical ,.t ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. <br /> PUMP REPLACEMENT: / / State Work Do- <br /> er T <br /> PUMP .REPAIR: / / State%'Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> F ,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. the well in use. The above F <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. ' <br /> SIGNED " TITLE <br /> 1 I ((DRAW'PLOT PLAN ON REVERSE SIDE)-,�� �. <br /> PHASE I FOR DEPARTMENT USE ONLY 7� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE JI 0 T INSP CTION PHA S III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> 4 ! <br /> E H 1426 Rev- . 1-74 <br />