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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. :Z 2,1,,),)- <br /> THIS <br /> -/Da-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. il <br /> I <br /> JOB ADDRESS/LOCATION CENSUS TRACT j <br /> Owner's Name Phone <br /> � .� <br /> Address _ � City <br /> Contractor's Name„ License Phone _q V1/ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION /—/ —PUMP REPAIR / / PUMP REPLACEMENT <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing y� <br /> Irrigation Gravel Pack Depth of Grout Seal V <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information V <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor P,6_e� T� <br /> Type of Pump I H.P. - <br /> PUMP REPL.?,CEMENT; State Work Done � 6.6.11 L_ <br /> PUMP ,.REPAIR: / / State Work Done <br /> DES.T�CTION 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 GROUT12LGZANP 4 FINAL INSPECTIO . <br /> SIGNED ` ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE J?-!-:Z2 <br /> E H 1426 Rev. 1-74 ' 1177 - 2M <br />