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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 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 G <br /> CENSUS TRACT <br /> Owner's Name % <br /> s <br /> �ne W <br /> Address r' <br /> City . . <br /> Contractor's Name License # 2� ---Phone <br /> TYPE OF WORK (Check): NEW WELL 'Lr DEEPEN -/-7 /RECONDITION /7 DESTRUCTIONj <br /> "f <br /> PUMP INSTALLATION./ -/ PUMP REPAIR PUMP REPLACEMENT / f <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES - PIT PRIVY <br /> SEWAGE-DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - <br /> PRIVATE <br /> DOE MESTIC WELL PUBLIC DOMESTIC WELL .� <br /> INTENDED USE TYPE OF WELL "CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. o.f-..WeI1. Excavation /Z1 � <br /> Domestic/private - Drilled --,-Dia. of Well• Caaing <br /> ;.D.omes.tic/public - 4 = Driven ''� <br /> Irrigation ..�su�e= of"Casing- � -�- �„---..-:---.- <br /> Gravel Pack Depth of Grout. Seal �- <br /> Cathodic Protection V Ratary Type of Grout 1 <br /> Disposal itOther Other Information <br /> Geophysical --�-- <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump <br /> *. H.P. <br /> PUMP REPLACEMENT: .,, /% State Work Done m �' <br /> PUMP .REPAIR: / / State Work Done. <br /> DESTRUCTION OF WELL: Well Diameter (� <br /> Describe-Material and Procedure Approximate-Depths i <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 /> atter completion of my work on a new well, I will furnish the San 'Joaquin Local Health District a 1 <br /> WELL DRILLERS ,REPORT of the well and notify them before putting the.-well in-use... The above i <br /> inf ormatitip is true to e-best•of- my knowledge and belief. I WILL, CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING D A AL I SPECTION. <br /> SIGNED TITLE, <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ~� t <br /> ADDITIONAL COMMENTS: DATE Ll��'�� <br /> t <br /> ]PHA IT GROUT INSPECTION PHAS IIT FINAL INSPECTION <br /> INSPECTION BY DATE - x_7 INSPECTION BY --dDATE - -' 1 ; <br /> E H 1426 Rev. 1--74 �./oe eu <br />