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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 1 YEAR FROM DATE ISSUED Date Issued -ZF <br /> Application is (Complete In Triplicate) <br /> iereby 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 <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address '7 <br /> r City . <br /> Contractor's Name s License # ?M Phone <br /> TYPE OF WORK (Check) : NEW WELL IX1 DEEPENI_I RECONDITION / DESTRUCTION /7 <br /> PUMP INSTAL ATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /% -- <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES PIT PRIVY ~ " <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 W <br /> Domestic/private Drilled Dia. of Well Casing f <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 B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,j <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> y <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 we11 '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 use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL.FOR A--GROUT INSPECTION <br />'RIOR TO ROUTING AN A FINAL INSPECTION. <br /> SIGNED <br /> ' TITLE <br /> E f <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />'RASE I FOR DEPARTMENT USE ONLY <br /> LPPLICATION ACCEPTED <br /> BY DATE <br /> LDDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C DATE <br /> E H 1426 Rev. 1-74 11177 2M <br />