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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TO—E,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 Date Issued <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 and the Rules and Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS AOC N = � CENSUS TRACT <br />; Owner's Name Phone <br /> Address City <br /> Contractor's Name License371�>Phond'9 679 ~ <br />€ <br /> TYPE4 OF WORK (Check)': NEW WELL -1-7 DEEPEN /7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR/7 PUMP REPLACEMENT /-7 <br /> h Other / f <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 �n <br /> Industrial jCable Tool - Dia. of Well Excavation \ <br /> f Domestic/privateiiP Drilled Dia. of Well Casing <br /> Domestic/public '. Driven Gauge of Casing > <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> f Cathodic Protection J 7°-T, 'Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ;, ' Surface Seal Installed BY: <br /> PUMP INSTALLATION C ►,--" Contractor <br /> Type, of Pump H.P. '7 <br /> PUMP­REPLACEMENT: • / / State'Woxk Done� <br /> PUl� REPAIR: _ `7I/- / 'State 'Work Done <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 /> N and the State of California -pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 /> 1PRIOR TO GROUTI G AND A''F NAL INSPECTION. <br /> SIGNED i, TITLE QIP <br /> (DZAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I� ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT 'INSPECTION PHASE III FINAL, INSPECTION <br /> I <br /> iNSPECTION BY DATE „INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />