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SAN JOAQUIN LOCAL. HEALTH DISTRICT _- <br /> EOR.OFFICE <br /> USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No2f <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is tereby 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSJLOCATION W CENSUS TRACT <br /> F Owner's Name Phone --Q <br /> Address m r <br /> City <br /> __..: <br /> Contractor's <br /> ,Name { License ./.7 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /;�// PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> `� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ~ <br /> CvVr -�� - SEWAGE-DISPOSAL' FIELD- `_69-SSP00L/SEEPAGE PIT OTHER <br /> PROPERTY LINE --PRI-VATE-DOMESTIC-WELL PUBLIC DOMESTIC WELL v <br /> INTENDED USE TYPE OF WELL I CONSTRUCTION SPECIFICATIONS W <br /> Industrial Cable Tool Dia.' ofWell Excavation /0 _ _00 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing A. - <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: <br /> PUMP INSTALLATION: .Contractor <br /> t { Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> k <br /> 3 PUMP 'REPAIR: / / State Work Done ` <br /> DESTRUCTION OFWELL: Well Diameter <br /> _ 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 /> r 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 ofthewell and notify them before putting the well in use. The above <br /> information is t to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO GRO G NAL CT IO <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> e <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY "� �� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE II/FINAL <br /> INSPECTION <br /> INSPECTION BY 41A222 'DATE INSPECTION BY DATE. <br /> 4kH 1426 Rev. 1-74 11177 _ 2M { <br />