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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR(OFFICE USE: ;f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �r1 1p fa <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _2� <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 s Name L Phone' <br /> Address - City <br /> Contractors Name %. �.l ,ij License one2207 <br /> TYPE OF WORK (Check): NEW WELL '/_7 DEEPEN -/? RECONDITION /_7 DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION / j PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other /_7 <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 /> PUME REPLACEMENT: State Work Done f-movE <br />-PUMP-'.REPAIR:- /_7 _State"Work'D' ie <br /> PES RUCTION 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 best.of- my.knowledge and belief. I WILL CALL FO A 'GROUT INS-EC ION <br /> PRIOR TO GROUTING AND A FI I ECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> .FOR D TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY6�22 (� DATE L` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA S II FINAL INSPECTION �f <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 E H 1426 Rev. 3-74 I-74 Im <br />