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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, Calif. +. <br /> Telephones (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. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> r - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name l p � Phone <br /> Address - City � . <br /> Contractor's Name License # ��� Phone <br /> -- _ <br /> TYPE OF WORK (Check) . NEW WELL /7 DEEPEN/_7 RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other J / <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 I Cable Tool Dia. of Well Excavation <br /> Domestic/private s Drilled Dia. of Well. Casing � <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation 3 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout! <br /> Disposal 1 Other Other Information ' <br /> Geophysical. I Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> r <br /> Type of. Pump H.P. <br /> PUMP REPLACEMENT / / . State Work Done i <br /> PUMP .REPAIR: w / State .Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 , <br /> I hereby agree to comply with -all laws and regulations of the San Joaquin Local Health District °': i <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-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL -INSPECTION. <br /> SIGNED TITLE <br /> "riD W IM PLAN ON REVRkSE SIDE ( ,. <br /> FOR DEPARTMENT USE ONLY o <br /> PHASE I <br /> APPLICATION ACCEPTED BY` DATE <br /> ADDITIONAL COHMTS: <br /> 'PHASE II GROUT INSPECTION PHASE FINAL INSPECTION , <br /> INSPECTION BY DATE INSPECTION BY DATE -7G <br /> E H 1426 Rev. 1-74 V76 214, <br />