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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF1;OFFICE USE: 1:601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:P (209) -466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In. Triplicate) <br /> Application is hereby mads: 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 3 '.2 � <br /> rQ ). CENSUS TRACT <br /> Owner's Name Z <br /> Phone <br /> Address <br /> City '' �✓ •- <br /> contractor's Name . License #CP& Phone <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN/? RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION J / PUMP REPAIRPUMP REPLACagaff J f <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK �' SEWER LINES PITi <br /> PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATEDOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> ' Industrial - CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavdtion Uv <br /> Domestic/Domestic/private CDrilled Dia. of Well Casing <br /> Irrigation <br /> Driven Gauge of Casing � <br /> Irrigation .�_ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary T34e of Grout ' <br /> Disposal _. Other Other :Information ' <br /> Geophysical Snrface'Seal Installed B <br /> - I <br /> PUMP INSTALLATION: Contractor„ <br /> Type .of Pump r <br /> H.P. f <br /> PUMP REPLACEMENT: • y ` <br /> State Work Done <br /> PUMP .REPAIR: State Work Done i <br /> _. . <br />)ES�TRUCT.ION. OF WELL: r_T Well...Diameter - <br /> Describe Material and Procedure,:.'` Approxiulate Depth r <br /> F <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 <br /> aELL DRILLERS REPORT of the well and notify them before putting.. the..well in.use.... The above <br /> Lnformation is true to- the-best-of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO G UTING AN A .FINAL INSPECTION. � <br />;IGNED <br /> TITLE . <br /> DRAW PLOT PLAN ON REVERSE SIDE <br />'HAS Ey ';iFOR DEPARTMENT USE ONLY <br />►PPLICATION:;,,A.CCEP.TED,BY DATE <br />►DDITIONAL `dokmiN.TS:�','`". -- ---� <br /> PHASE ITOUT INSPECTION PHASE YIT SINAL INSPECTI <br />:N P E CT 10 N,B Y7, ,1,. f , : DATA INSPECTION BY d DATE <br /> �;,.. <br /> E H 1426 Rev. 1-74 <br />