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°'AN JOAQUIN LOCAL HEALTH DISTRI <br /> FO&.OFFICE USE: lE E. Hazelton Ave. , Stockton, Ca_zf. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION ORPUMPPERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISS <br /> tsued �(Complete In Triplicate) i_eA plication is hereby made to the San Joaquin Local Health District fo!?E <br /> iconstruct <br /> ad/or install the work herein described. <br /> C This application is made in compliance with San Joaqu: <br /> unty Ordinance No. 188622 and the <br /> Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name y • <br /> Phone <br /> Address rL/il j. 7-P A/� <br /> , .r.. City <br /> Contractor's Name " A ? icense Phon d2y/ <br /> TYPE OF WORK (Check) ; NEW WELL /frOO'OBEEPEN RECONDITION /7 DESTRUCTION //f <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / •— <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 ,r <br /> �! Domestic/private Drilled Dia, of Well Casing <br /> - Domestic/public Driven Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection 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 /> r <br /> PUMP REPLACEMENT: / / State Work Done �. <br /> PUMP-REPAIR: State Work Done <br /> r <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth �< <br />,i 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRMITINQ AND A FINAL INSPECTVIN <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDS <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:/ 44 <br /> ? —�- <br /> GRMT INSPECTIONPHASE III/FINAL INSPECTION <br /> INSPECTION DATE INSPECTION BY DATE i 6 <br /> E H 1426 Rev. 1-74 <br />