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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �r <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 ereby made 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 <br /> nn Joaquin Local Health District. <br /> JOB A <br /> DDRESS/LOCATION lL�r. _Y CENSUS TRACT <br /> OwnerN�a m1f; Phone A <br /> Address _ City <br /> Contractor's Name License #j(,)_373 Phone�J-M� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION 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 N, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing C <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: v <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. <br /> -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done e <br /> DESTRUCTION 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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT MD A F INSPE ION. <br /> SIGNED TITLE <br /> W ' T PLAN ON REV' 'kSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /� <br /> APPLICATION ACCEPTED BY (� d DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE ION PHAS I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE "' <br /> E H 1426 Rev. 1-74 3/76 2M <br />