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!� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOZ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> /APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .35Gc1 <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 d 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 - <br /> Phone <br /> Address �L City . <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/ZT RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR/? PUMP REPLACEMENT /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 SPECIFICATIONS <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 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ��� Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump , <br /> . H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,REPAIR: /7 State Work Done . <br /> OES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 <br /> information is true to the-best-of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR U NG D A NAL INSPECTION. <br /> SIGNED c TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> kPP-TION ACCEPTED BY - - <br /> kDDITIONAL COMMENTS: t DATE <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> C13SPECTION BY _ DATE INSPECTION BY TDAT <br /> f <br /> E H 1426 Rev. 1-74 - r 1.k7e „M <br />