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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR 0 FICE 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 �� <br /> (Complete In Triplicate) <br /> kApplication 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 /> 4 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 i Phone j ? <br /> 22 <br /> Address [' City . <br /> Contractor's Name ! r License � 3L/Y Phone ,S <br /> TYPE OF WORK (Check) : NEW WELL 'Al DEEPEN, /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR /�/Y PUMP REPLACEMENT /_7 <br /> f - --Other-- <br /> I <br /> -Other-I DISTANCE TO NEAREST: SE1. PTIC TANK/�DfJ SEWER LINES PIT PRIVY <br /> `SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> x INTENDED USE >- TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 0; Industrial ^ Cable Tool Dia. of Well Excavation `r <br /> Domestic/private Drilled Dia. of Well Casing -� V <br /> Domestic/public: Driven Gauge of Casing r <br /> Irrigation } • Gravel Pack Depth of Grout Seal V] <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> 4 Geophysical <' Surface Seal Installed By: TTS <br /> PU ' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP` REPLACEMENT: / / State Work Done <br /> PUMPREPAIR: / / State Work Done <br /> DERUCTION OF WELL: 'Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />{ I h-ereby agree to comp1-y-with-a1-1• 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 /> rafter completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br />• WELL DRILLERS REPORT of theTwell` and notify them before putting the.-well in use. The above •. <br /> information is true too the_ _e two _ my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />-:PRIOR TO T G D °A FI A TION. <br /> SIGNED TITLE <br />' 4 (DRAW PLOT PLAN ON REVERSE SIDE)" , <br /> I' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY +DATE ' <br /> i ADDITIONAL COMMENTS: Z <br /> PHASE IItG U IN PECTION PMqP41/FINAL P1/FINALINSPECTION <br /> INSPECTION BY DATEINSPECTION B DATE '�, <br /> E H 1426 Rev. 1-74 2M r <br />