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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 �� 7 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J <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 el CENSUS TRACT <br /> Ownerts Nameoar <br /> AL Phone <br /> Address - <br /> /I tfy City <br /> Contractor's Name License Phone _o <br /> TYPE OF WORK (Check): NEW WELL DEEPENJ_7 RECONDITION /_7 DESTRUCTION f7 N <br /> PUMP INS ALLATION PUMP REPAIR /� PUMP REPLACEMENT71_7 LA <br /> Other /% N <br /> --- %A <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIgg= PIT PRIVY C� N <br /> SEWAGE DISPO AL FIELD jr& CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL Ifs 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: 7z7,;/_37< . <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpZia H.P. <br /> PUMP REPLACEMENT: %/ State Work Done <br /> P'[4'^,.REPAIR:— - /_7' State Work Done <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 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 puttingthe well in use. The above <br /> information is true to the beat of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPEC710N. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br />—ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY r DATE i INSPECTION BY D T <br /> ~E H 1426 Rev. 1-74 1-74 2M <br />