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( SAN JOAQUIN LOCAL -HEALTH DISTRICT f F7 <br /> FORIOFFICE USE: 1601 E. Hazelton e <br /> . on Ave. , Stockton, Calif'. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES L 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 andel the Rules and Regulations off the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �/ /� r�� er CENSUS TRACT <br /> Owner's Name If? Phone <br /> Address City 5�46 ` <br /> Contractor's Name _�� �? res' License #�cs____J Phone <br /> TYPE OF WORK (Check): NEW WELL 97 DEEPEN /7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /OD SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER t <br /> PROPERTY LINE WPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USF: 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 V k Gravel Pack Depth of Grout Seal -��, r2 <br /> Cathodic Protection Rotary Type of Grout ,r- <br /> Disposal Other Other Information, <br /> Geophysical Surf ace Seal. Installed By; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / T'f H.P. 3 t' <br /> i <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP :REPAIR: /7 Statb Work 'Done _ —' ter. <br /> /y^. <br /> ,,ES-TRUCTION 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 regulat.ig 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 t well and notify them before putting.the..well. in-use. The above <br /> information is true t he. est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT A F ECT <br /> SIGNED <br /> M ,.-(DRAW. PLOT PLAN ON REVERSE SID .. <br /> F'OR-DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ~ �' `DATE <br /> ADDITIONAL COMMENTS: a <br /> PHAS I GROJIT INSPECTION/ PISA" T;ZIFYNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ^E H 1426 Rev. :1-74 ' _ . 1-7/A ?M <br />