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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk -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 1 YEAR FROM DATE ISSUED Date Issued z z z . <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 anA the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION D { CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name License ��� 'Phone <br /> g�' !4 <br />' TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / /' PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br />� o <br /> DISTANCE TO NEAREST:-SEPTIC [TANK Lo I SEWER LINES PIT PRIVY " <br /> f SEWAGE DISPOSAL FIELD C S POOL/SEEPAGE PIT < OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLi <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial # Cable Tool Dia, of Well Excavation <br /> �Domestic/private 1. Vbrill.ed -- Dia. of Well Casing U <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ( Gravel Pack Depth of Grout Seal <br /> Cathodic Protection VRotary 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: / / State Work Done f . <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter , p Approximate Depth <br /> Describe Material and Procedure ' X, <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 op- 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 thewell in use.... The above <br /> information is true to the best of myl-.knowledge and belief. I WILL CALL FOR- A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALiINSPECTION. <br /> SIGNED , 1 TITLES <br /> 1 (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION— PHASE ITI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /r j` •,. DATE /0'3J-7? <br /> r <br /> E H 1426 Rev. - I-74 6177 _ 2M <br />