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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1.601 E. Hazelton Ave. , Stockton$ Calif. <br /> ' Telephone: (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 /> �t�laere made to the San Joaquin Local Health District for a permit to construct <br /> Application is <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> s and Regulations of the San Joaquin Local Health District.. <br /> County Ordinance Na. 1862 and the Rul <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> 4 Phone <br /> �. <br /> Owner's Name , <br /> Address City <br /> License <br /> Contractor's Name <br /> j' TYPE OF WORK (Check) : NEW WELL /` DEEPEN '/� RECONDITION DESTRUCTION %T <br /> PUMP INSTALLATION I / PUMP REPAIR/PUMP REPLACEMENT �T <br /> f Other /7 <br /> t <br /> DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTB$R <br /> PROPERTY -LINE -- PRIVATE DOMESTIC WELL PUBLIC. DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial y '�'= Cable Tool Dia. of Well. Excavation <br /> �Domestic/private x .r. 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 /> FOther _ Other Information <br /> Disposal <br /> Geophysical :y` ' '' z _ Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> F Type of Pump H.P. <br /> PUMP REPLACEMENT: - j State Work Done <br /> k. <br /> -PUMP-REPAIR: 4 -- - / -- State Work,Do ' <br /> Approximate Depth <br /> DESTRUCTION 'OF WELL: Well Diameter, <br /> Describe Material and Procedure <br /> I .hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distr ct <br /> and the State._,of California pertaining to or regulating well"construction. Within FIFTEEN DA,I5 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health DistriM . <br /> ct a <br /> WELL DRILLERS REPORT of the well and notify them before putting the.. 11 in use. The above <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT I_ISPECTION.- <br /> PRIOR TO GROUT NG AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D yd' PLAN ONtSE SIDE <br /> FOIX DEPARTMENT USE ONLY <br /> PHASE I DATE / <br /> APPLICATION ACCEPTED BY <br /> ADDITIONALf]MMENTS: . <br /> + PHASE II ROUT IN51'BCTIOI o w< ow PHASE III FINAL 1 PECTIO <br /> VD <br /> INSPECTION BY DATE INSPECTION BY DATE t <br /> drib - gg <br /> E H 1426 -Rev. 1-74 <br />