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j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FR,,OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> 1 F <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In jriplicate) <br /> Application is hereby made to the San ,Joaquin Local Health District for a perm <br /> it- cort`etruct <br /> and/or install the work herein described. This application is made in' compliahce with''San Joaquin: <br /> ilCounty Ordinance No. 1862' artd the Rules and Regulations of the San Joaquin Local Health District.. <br /> .TOB ADDRESS/LOCATION r CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> j City . . <br /> Contractor's Name - <br /> License # PhoneIN I <br /> .�-�' � <br /> TYPE OF WORK (Check): NEW -WELL DEEPEN '/_7 RECONDITION /-7 DESTRUCTION FT <br /> PUMP INSTALLATION / / 1PUMP REPAIR /? PUMP REPLACEMENT /7 <br /> Other]/-7 <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 4' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS <br /> Industrial iCable Tool Dia. of Well Excavation O <br /> Domestic/private i Drilled Dia. of Well Casing /62 <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation.- ! Gravel Pack Depth of Grout Seal. ! <br /> Cathodic ProtectionRotary - Type1of Grout f <br /> Disposal i Other ` ','OthePInformation, <br /> Geophysical <br /> _ } Surface Seal Installed 'By: <br /> PUMP <br /> INSTALLATION: t <br /> Type :of Pump I ! :.{ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: <br /> _/ 7 S ate Work Done <br /> € Fr, <br /> DESTRUCTION OF WELL; Well Diameter " -'Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertafining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work0i/� newtwell, I will furnish the San Joaquin Local Health District a f <br /> WELL DRILLERS REPORT of the wellNand notify them before putting.- the..wel1. in,use.... The above I <br /> information is true to the-bes;t of`."My.kriowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO T G A NAL INSPECTION , <br /> SIGNED - TITLE <br /> ,(DRAW PLOT PLAN ON REVERSE SIDE)f <br /> �. FOR DEPARTMENT USE ONLY ; <br /> PHASE I ' , - <br /> APPLICATION ACCEPTED BY _ _jam. ,, !x , <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IiVSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BYDATE -:� INSPECTION BY DATE/c-Zf7� <br /> E H 1426 Rev. 1-74' f 1.I7r "" <br />