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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 PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate)— <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described his application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 JaPthe Ru e d Regulations of he San Joaquin Local Health District. ` <br /> JJOB ADDRESS/I OCATM,5 CENSUS TRACT <br /> Owner's Name Phone SCJ T <br /> Address / City <br /> Contractor's Name License-40�" Phon <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN /�/ RECONDITION /_7 'DESTRUCTION <br /> AL <br /> PUMP INSTLATION '/ / PUMP REPAIR PUMP REPLACEMENTF-f7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \: <br /> Industrial Cable Tool Dia, of Well Excavation W <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 /> f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done K <br /> PUMP--REPAIR: - A —State -Work-Don - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> P P p <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 G&2UTING AND A FINAL INSPECTION, <br /> SIGNED TITLE 1 <br /> D P PLAN ON REVERSE SIDE #. ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I L <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL �OMM$NTS: <br /> PHASE II 4WOMXINSPECTION PHASE III FINAL INSPECTION . <br /> INSPECTION BY -DATE INSPECTION BYDATE <br /> 4;Z6<7 <br /> i <br /> 3/76 2i <br /> E H 1426 Rev. 174 m <br />