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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 456--6781 "`"` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S <br />� <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin focal 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. 1A362 and the Rules and Regulations of the San Joaquin Local Health District. <br /> d/ <br /> JOB ADDRESS/LOCATIOmN1 C CENSUS TRACT <br /> Owner's Name 7 Phone L <br /> Address ,� City <br /> Contractor's Name t S License phone <br /> ?p <br /> TYPE OF WORK (Check): NEW WELL/t DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /-7 4 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other 7 <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 11 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigations Gravel Pack Depth' of Grout Seal <br /> Cathodic Protection _�/ Rotary Type of Grout <br /> Disposal <br /> Geoa Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP �REPAIR: - / / State Work Done <br /> ES•TRUCTION 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 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 /> PRIOR TO G OUTING AND FINAL I PECTIO. <br /> SIGNED ITLE <br /> (D PLOT LAN ON REV SE SIDE) J <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED- Y DATE <br /> ADDITIONAL COMMENTS: Oa447 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _... INSPECTION BY DATE <br /> t E H 1426 Rev. 1-74 <br /> 1-74 2M <br />