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F.OR 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., Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (complete Date Issued � ) <br /> Application is Aereby made to the San Jo quin Triplicate)In <br /> Local District for a permit <br /> and/or install the work herein described. This application is made incompliancetwithnSan uJoaquin <br /> County Ordinance No. 1862 and the Rules nd Regulations of he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Address � Phone <br /> �� <br /> Citye�r <br /> Contractor's Name License 143 10"o-ot Phone <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN _ i <br /> RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK , <br /> 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 <br /> Industrial '� 'CONSTRUCTION SPECIFICATIONS <br /> 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 /> gathodic.'Protectlon. Rotary Type_ of Grout <br /> Disposal Other - - <br /> Other Information <br /> Geophysical <br /> Surface Seal Installed <br /> PUMP INSTALLATION: ContractorC�a <br /> Type of Pump <br /> H.P. <br />'UMP REPLACEMENT: State Work Done <br />?UMP •.REPAIR: / / State Work Done <br /> LES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health bistrict <br />,nd the State of California pertaining to or .re.gulating,well 'construction. Within FIFTEEN DAYS <br />.iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> nformation is true to the best ofmy knowledge and .belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO G OUTING AND FINAL INSPECTION. <br /> IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY DATE � _/L. - �' <br /> DDITIONAL COMMENTS; w _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY <br /> --��.,_ DATE <br /> -E H 1426 Rev. 1-74 -. 1 177 .,,r <br />