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w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.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' l YEAR FROM DATE ISSUED Date Issued 7f <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. <br /> JOB ADDRESS/LOCATION�� '�? (� CENSUS TRACT <br /> F _ <br /> F.�r <br /> Owner's Name .� Phone �`gi,( <br /> � <br /> r <br /> Address City Il l�o r <br /> 3 <br /> f Contractor's,• Name d License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPENS/+/ RECONDITION / / � DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT •� !'`� <br /> ' Other / / '' e T, k <br /> DISTANCE'TG-'NEAREST: SEPTIC TANK SEWER \LINES PIT PRIVY:' Y� �^� VM <br /> SEWAGE DISPOSAL FIELDS A _ CE55POOL/SEEPAGE PIT �" OTHER <br /> PROPERTY LI -RIUAE DOMESTICWL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool -Dia. of-Well Excavation <br /> ---1� Domestic/privateDrilled Dia of Well Casing <br /> 'Domestic/public Driven Gauge of Casing •� <br />€ 'Irrigation ' Gravel-14a°ck Depth of Grout Seal " <br /> Cathodic Protection Rotary;`` Type of Grout <br /> D'i'sposal OEherOther Information <br /> ;Geophysical <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor /[J ' <br /> Ty�pef~'Pump _� f� _ 15 �: H.P. 3 <br /> PUMP REPLACEMENT: State Work Done e SO-5 <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 /> f 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-GROUTING AND A FINAL INSPECTION. <br /> E <br /> SIGND ' <br /> � � - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) '! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I, <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GPDJJT INSPECTION PHAS I I/FI INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DATE` <br /> E H 1426 Rev. 1-74 <br />