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t <br /> SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOErOFFICE USE: 1601 E. Hazelton:Ave. ,'Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR,FROM DATE ISSUED Date Issued <br /> k, ) (Complete In Triplicate) , <br /> Application is hereby made to the San Joaquin.Local. Health Diatrict for a permit to- construct f <br /> and/or instal.l�the,work hereiia-described. >, This application -is made in compliance with San Joaquink <br /> County Ordinance.1No:-1862 andl the-Rules d.Regu ations.<of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONc. - /, - <br /> l..x CENSUS TRACT <br /> Owner's NameF d <br /> Phone -� <br /> Address <br /> Contractor's Name '" <br /> License id Phone <br /> _ F <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN /_7 - RECONDITION /_' DESTRUCTION /`7 a <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other T7 <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 rUSE ',HYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private ri Drilled -Dia.- of Well Casing <br /> Domestic/public r Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection- j Rotary - Type of :Grout <br /> Disposal I, Other Other Information <br /> Geophysical. I Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPATR: �-7 State- Work Done <br /> ES7RUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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•beet-of. my knowledge and belief. I WILL <br /> PRIOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN A FINAL INP ION. <br /> SIGNED TITL i <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I __ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ". <br /> PHASE If CRMMT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY- 8C DATE p -Q-La <br /> a <br />�� E H 1426 Rev. 1-74 1-74 2M <br />