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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR-OFFICE'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5 -l� 7d <br /> - (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application ismade in compliance with San, Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of th S Joaquin Local. Health Dfstrtct. <br /> JOB ADDRESS/LOCATION <br /> CENSUS- TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City . . <br /> Contractor's Name . . J- Q' <br /> License Phone <br /> N <br /> TYPE OF WORK (Check) :11 NEW WELL/ / DEEPEN RECONDITION /_-7 DESTRUCTION /_7 ; <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE <br /> PROPERTY_ LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ryTYPE OF WELL VI)CONSTRUCTION SPEGIFICATIONS <br /> =Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privates F Drilled Dia, of Well Casing <br /> Domestic/public —7 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 <br /> Surface Seal Installed B ; <br /> PUMP INSTALLATION: Contractor / <br /> Type of <br /> Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> State -Work Done , <br /> PUMP '.REPAIR: <br /> t / / State Work Done <br /> DE5•TRUCTTON OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 />?RIOR TO OUTING N INSPECTION. <br /> SIGNED <br /> TITLE <br /> t .(DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � ��� / <br /> kkDDITIONAL COMMENTS: f 7 <br /> DATE <br /> PHASEII GROUT INSPECTION PHAS II/FINAL INSPECTION f <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1177 ! <br />