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SAN JOAQUIN LOCAs. HEALTH DISTRICT <br /> FOF� OFFICE <br /> USE.- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9 <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. 1862laand the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �i Z f CENSUS TRACT <br /> Owner's Name Phone <br /> Address j - <br /> City � .1,t? /V ... <br /> Contractor's Name License G MPhone <br /> TYPE OF WORK (Check):- NEW WELL -L-7 DEEPEN /7 .RECONDITION .7 DESTRUCTION. f7 <br /> PUMP INSTALLATION / / PUMP REPAIR -,& PUMP REPLACEMENT 17 <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 <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. _ »� '� ' <br /> -Surface Seal 'Installed By: <br /> PUMP- INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: 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 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 G OUTING AN NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 'a <br /> APPLICATION ACCEPTED BY � DATE 1�J16 <br /> ADDITIONAL COMMENTS: ci <br /> PHASE II GROUT INSPECTION PHASE-lENSPECTIOlk <br /> INSPECTION BY DATE INSPECTION BY E <br /> _ 6 <br /> E H 1426 Rev:1--74--- 2M -� <br />