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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR QFFICE4 USE: 1601 E. Hazelton- Ave. ,-' Stockton, Calif. } j� � � <br /> Telephone ; (209) 466-6781 <br /> �1�1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE T Permit No, •-�a <br /> i <br /> THIS PERMIT EXPIRES. I YEAR FROM;DATE ISSUED Date Issued <br /> (Complete In Triplicate) 1 <br /> Application is hereby made to the San Joaquin Local .Health District -for a permit to construct j <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. , _ CENSUS .TRACT <br /> Owner's Name Phoneme <br /> Address City S� �� - -- <br /> Contractor's Name License #41?t&-)Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / 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 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 -_ .s=Rotary- Type of Grout <br /> Disposal Other, OtIfer Information <br /> Geophysical Su-rface Seal Installed By- <br /> PUMP <br /> INSTALLATION: Contractor ' ' <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done f ES� 44 <br /> _ Q <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 putting. the well in use... Ttfd above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR At`GROUT fIN.SPECT;ION <br /> PRIOR TOG UTING ANP A FTPAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAG PLOT PLAN ON REVERSE SIDt;) I' <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> i, APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II O T I TI6N PIJAS . JTAIFINA INSPECTION <br /> INSPECTION BY ATE INSPECTION B ATE /„o/-V-77 <br /> UZ <br /> 6/77 _ <br /> E H- 1426 RPu. . 1-74 <br />