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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FGA OFFICE USE: V 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 2z:! l/a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> In 2� <br /> Application is hereby made to the San (Joaquin eLo alrHealthtDistrict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address !iQ t <br /> City _ <br /> Contractor's Name <br /> G__ License Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> / I DEEPEN / / RECONDITION /% DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <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 /> ri 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 V� <br /> Geophysical Surface Seal Installed B ; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. — <br />'UMP REPLACEMENT: State Work Done \ <br />'UMP .REPAIR: State Work Done , <br />�ES,TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />,nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />.fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the well and notify them before putting the- well in use.. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> RIOR TO GRO INC AND A FINAL_ INSPECT ON. <br /> IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY 1,1/ DATE '7� �7 <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PW�44IJI/F13AL INSPECTION <br /> 9SPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 11177 . 214 <br />