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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F S OFFICE USE: �� 1601 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 iDate; Issued ._—a gLL-7, <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 is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andtheRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I(� (� Illev CENSUS TRACT <br /> Owner's Name Phone <br /> Address ��-a- � � - City <br /> Co :tractor Is Name ' I License # Phone W ba S <br /> TYPE OF WORK (Check)NEW WELL -/-7 'DEEPEN -/ RECONDITION I7 DESTRUCTION I-T :- <br /> PUMP INSTALLATION / / PUMP REPAIR `PUMP REPLACEMENT f 7 <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 A � v <br /> Domestic/private Drilled Dia. -o€ Well Casing �. <br /> Domestic/public Driven Gauge of Casing i <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 B <br /> PUMP INSTALLATION: . Contractor <br /> Type .of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: State Work Done 1 � <br /> RESTRUCTION 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 Districta <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 GRO TING AND A IINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ' <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INS ECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE � F <br /> E H 1426 Rev. 1-74 <br />