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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 I 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 Reulations of the San Joaquin Local Health District. <br /> . amu.--� <br /> I JOB ADDRESS/LOCATIONS CENSUS TRACT <br /> - - <br /> Owner's Name Phone36 <br /> Address City <br /> Contractor's Name License #16 1...37.3 PhoneJ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDI ON / --)DESTRUCTION /- <br /> PUMP INSTALLATION / / PUNP-RF,PA • REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -� SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER QQ <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 S <br /> Domestic/privateDrilled Dia. of Well Casing <br /> * s <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 /> PUMP REPLACEMENT: f <br /> State Work Done <br /> PUMP :REPAIR: � r <br /> / ,State Work Done <br /> DESTRUCTION OF WELL: Well Diameter a ,'� Appro imate. Depth <br /> De's'c'ribe-Matefrial an21 Pro—cedure <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 -dse.: The above <br /> information is ue to the est of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU D A F AL INSPE TION. ' 4 <br /> SIGNED TITLE Ah <br /> W PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT iI�"-ONLY <br /> - <br /> APPLICATION ACCEPTED BYA%lq -- DATA Z.3 <br /> Y <br /> ADDITIONAL COMMENTS: � <br /> - 21 <br /> PHASE LI ROUT INSPECTION HASE /-FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE <br /> E H 1426 Rev. - I-74 b/7.7 _ 2M <br />