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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601E. Hazelton Ave. , Stockton, Calif. C 5 <br /> C Telephone: (209) 466-67-81- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -;717 <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 and the Rule and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA N � / <br /> CENSUS TRACT <br /> Owner's Name f <br /> Phone - <br /> Address <br /> Contractor's Name <br /> License 3-�3Phone <br /> TYPE-OF WORK-'(Check) NEW WE ,I.�'/ f "DEEPEN %/4 REGONDITIO <br /> F �. F iI DESTRUCTION /� <br /> PUMP INSTALLATION. / / PUMP REPAIR /'}Q PUMP REPLACEMENT /? <br /> Other' / -/ _ 7"-` <br /> DISTANCE TO NEAREST: SEPTIC TANK ; S <br /> ' EWER-LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> r INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> ' Domes'tic/private Drilled ., Dia. of Well Casingg <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Other Other Information <br /> Geophysical <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION Contractor <br /> Type of Pump <br /> H.P. <br />,PUMP REPLACEMENT: / / State -Work Done <br /> PUMP REPAIR: w - Statd Work Do <br />'DES-TRUCTION OF WELL: Well Diameter - <br /> Describe Material and Procedure Approximate Depth <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 I <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 INSPECTIO <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: } <br /> PHASE II GROUT INSPECTIONPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE w' INSPECTION BY G'p DATE <br /> tE H 1426 Rev. 1•-74 <br /> _ 1 A 7 7 oar <br />