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h - <br /> ` � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 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 Regulation the San Joaquin Local Health District`. <br /> JOB ADDRESS/LOCATION c � G' CENSUS TRACT <br /> Owner's Names -' Phone /J a <br /> Address ��� City <br /> Contractor's Name Z Licensed Phone & <br /> -a <br /> TYPE OF WORK (Check); NEW WELL J7 DEEPEN/ / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR J J PUMP REPLACEMENT <br /> Other�/ J <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ~OTHER <br /> YPROPER LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial 1 Cable Tool Dia. of Well- Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of 'Casing -. <br /> Irrigation F Gravel Pack Depth of"Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> ;PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PULP REPLACEMENT: / J State Work Done <br /> PUMP .REPAIR: / J State Work Done <br /> DESTRUCTION,OF,WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 14herebY_a tee to, comply+with all:-laws and re ulations of., <br /> the San Joaquin Local Health Histrict i <br /> and the State-of California pertaining to or regulating well'-conetruction. Within FIB' SK DAYS i <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 abave 1 <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT ViSPECTIo�+I; <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W.. PLAN RSE SIDE "l, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> 'PRASE-1I GROUT INSPECTION PHAS 11 INSPECTIO <br /> INSPECTIOPN BY DATE INSPECTION BY DATE <br /> V76 <br />" ... E H 1426 :Rev. 174 - ... . _ � <br />