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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 ADDRESSQ�= ellCENSUS�f` fj a TRACT <br /> Owner's Name X11 Phone <br /> Address City <br /> Contractor's Name �'/�'l t r ZLicense i7eo4phone��` <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 .�, 0 4-SEWER LINES -PIT PRIVY <br /> SEWAGE DISPOS*} IELD — CESSPOOL/SEEPAGE PITrd" --r-OTHER r" <br /> PROPERTY LI�TF�- RIVATE DOMESTIC WELL570- IIBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled ; Dia, of Well Casing 5 • <br /> Domestic/public Driven Gauge of Casing l i <br /> Irrigation Gravel Pack Depth of Grout Seal 41 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - <br /> _ 4'r dyL <br /> oc <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter { Approximate Depth <br /> Describe, MAteria nd rocedure <br /> I hereby agree to comply with -all laws dhd regulations of the San Joaquin Local eal_th 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 Distract 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 <br /> ( W PLO VL& ON REVERSE SIDE} <br /> FOR DEPA TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED C DATE <br /> ADDITIONAL, COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ��T <br /> } <br /> E H 1426 Rev. - 1-74 0��%7 _ 2M /" <br />