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rile � I �v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. �1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?6»/9s;," <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/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License Phone , 4Vz� <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN '/� RECONDITION _ DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP 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 (/1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 11 <br /> Industrial Cable Tool Dia. of Well Excavation1 <br /> Domestic/private Drilled Dia. of Well Casing <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 B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT %/ State Work Done <br /> PUMP :REPAIR: /7 State Work Done AW �S <br /> bES•TRUCTION OF WELL: Well Diameter Approximate Dept <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. my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE ]2�j, <br /> DRAW PLOT PLAN ON REVERSE SID .••..•.�..- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ADDITIONAL CON COMMENTS: <br /> PHASE II CTION PHASE III FINAL INSPECTION <br /> INSPECTION BY E INSPECTION BY DATE <br /> E S 1426 Rev. 1-74 ?5 2M -- <br />