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— = SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � _ <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PE1 If, PIrm No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicatio s eeeby 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 i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z4 �� �NSUS TRACT <br /> Owner's Name �fPhone <br /> Address City <br /> Contractor's Name License 4��_� Phone,3� b <br /> i <br /> TYPE OF WORKCheck) : NEW WELL _ __ __ <br /> ( DEEPN / / RECONDITION / / DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR J / PUMP REPLACEMENT <br /> Other <br /> DISTAN E TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> � t PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI TIONS <br /> Industrial _ able Tool Dia. of Well Excavation <br /> ✓Domestic/private Drilled Dia, of Well Casing `/ <br /> Domestic/public Driven Gauge of Casing leg er-4 <br /> irrigation Gravel Pack Depth of Grout Seal 7 la a _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor \ r '- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �d Approximate Depth-,--�.f_ <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 wellin 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 GRO ING AN A Fa L SPECTION. .--- <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ed ��,�/ DATE -�-`- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> E H- 1426 Rev. 1-74 <br />