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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PLO <br /> OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PermitJ- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��d, � <br /> (Complete In Triplicate) <br /> Application is 4ereby made to the San Joaquin Local Health Distract 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 ^d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION "" `" CENSUS TRACT <br /> Owner's Name n-Y.�' �L {.� Phone Zf <br /> Address / city <br /> Contractor's Name License IV <br /> PhoneJ�� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION & PUMP REPAIR/—/ PUMP REPLACEMENT /_7 <br /> Other <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 t� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q}. <br /> Industrial Cable fool Dia, of Well Excavation <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. j:� g2 ` <br /> PUMP REPLACEMENT: / / State Work Done p7 [J <br /> PUMP .REPAIR: / / State Work Done <br /> DES•TRUCTION OF WELL: Well Diameter Approximate Depth <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 GFAUTIVG AND A FINALNS CT <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE d <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATEia <br /> E H 1426 Rev. 1-74 11/7 . .- . 2M <br />