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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> iTHIS 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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION G --�C� CENSUS TRACT <br /> Owner's Name s� Phone <br /> Address �,/G y� City <br /> Contractor's Name License #C4f:? Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / FUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES loo PIT PRIVY <br /> SEWAGE DISPOSAL FIELD —� CESSPOOL/SEEPAGE PIT OTHER` s <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 � t <br /> X Domestic/private Drilled Dia, of Well Casing L!� �V <br /> Domestic/public Driven Gauge of Casing 1&X4 <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 �y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximatq Deptly <br /> Describe Material and Procedure <br /> I hereby agree to comply 'fi7 th all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pe ainin➢g=t-o-or. regulating well "construction. Within-FIFTEEN DAYS E <br /> after completion of my work on a new well, I will furnish the San JJoaquin L co al�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 GROUTINA AND A F jNAL INSPECTION. <br /> SIGNED TITLE l <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHqy2jI GRQYJT INSPECTIO P E /FIN INSPECTION <br /> INSPECTION BY DATE 7 INSPECTION BY DATE X2 '7/ <br /> r <br /> � <br /> 1426 Rev.. 1].-74 .. - -.""� �� 117.7 <br />