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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE_.USE: 1"601 E. Hazelton 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 toi the Sats 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. l8 2 and the "RRullJes and Regulations of: the San Joaquin Local Health District. <br /> fjV� CENSUS TRACT <br /> JOB ADDRESS/LOCATi � <br /> _ <br /> PhoneAt me <br /> Owner's Name <br /> cityxa+-� <br /> Address <br /> Contractor's Name�'� <br /> License ��7' �►one <br /> TYPE OF WORK Check}; NEW WELL /� DEEPEN '/=T RECONDiTI N 17 DESTRUCTION j P <br /> ( PUMP INSTALLATION / / PUMP REPAIR _0 PUMP REPLACEMENT /? <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 I Cable Tool Dia. of <br /> Well Excavation <br /> 4 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> t Irrigation i 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 <br /> Type hof Pump H.P. <br /> I <br /> PUMP RgPLACEIIENT: E7 !State Work Done <br /> "PUMP-'REPAIR: " " 3StategWork Dorte <br /> IES�TRUCTION OF WELL: Well Cameter Approximate Depth <br /> t Describe Material and Procedure <br /> h I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health District <br /> j and the State of Californiatpertaining 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 thewell 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> .FOR DEPARTMENT USE ONLY <br /> -:PHASE I DATE <br /> '_APPLICATION'_APPLICATION ACCEPTED BY . <br /> "'ADDI3� ()1AL <br /> COMMENTS: <br /> PHA FI INSPECT-- N <br /> PHASE II GROUT' INSPECTiON DATE <br /> i1ECT1 �BI f DATE INSPECTION BY <br /> 1 1 1 <br /> 1-74 2M <br /> , �,E ,,X426 Rev. 1-74 <br />