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- SAN JOAQUIN LOCAL HEALTH DISTRICT L V t � <br /> PFOK-OFF�10E U 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: -1(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 / CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name - License �� 1 Phone Q 3f <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN / / RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V_ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER VA <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL --- PUBLIC DOMESTIC WELL VI <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIO S <br /> industrial Cable Tool Dia. of Well Excavation <br /> V156mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection __jf!�­Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> J <br /> PUMP .REPAIR:.e. / / State Work Done <br /> DESTRUCTION 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 J qu Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting th well i use. The above <br /> information is tf to-the-best o my knowledge and belief. I WILL L Fj A GROUT CTION <br /> PRIOR TO GROU D A FINAL 10 <br /> ECTION. <br /> SIGNED TITLE <br /> i` DRAW PIZ T PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ON , <br /> PHASE I r DATE �.�c/ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: elz f <br /> PHASE II GROUT..INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Q DATE <br /> 3/76 214 <br /> E H 1426 Rev. 1-74 <br />