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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0TZFFICE 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/LOCATIONJ� -2 $, CENSUS TRACT <br /> Owner i s Name r Phone 3 Y 7 _y y <br /> Address City <br /> Contractorts Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/? RECONDITION /-7 DESTRUCTION /7 <br /> POUPrnrI�SALLATION / / <br /> PUMP REPAIR /-J PUMP REPLACEMENT /? <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 <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 /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / IT State Work Done <br /> PIW :REPAIR-. /-7 State Work Done <br /> ES•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 /> 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 EMUIN2 ANR.. MAL INS CTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE --Zcs- � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIA/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 'i E H 1426 Rev. 1-74 <br /> 1--74 2M <br />