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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRRUCTION OR PUMP PERMIT Permit No. - 9/d✓I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Y <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 Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ;el CENSUS TRACT <br /> Owner's Name Phone j <br /> Address City ' <br /> Contractor's Name a License # '7411 Q Phone <br /> TYPE OF WORK (Check) NEW WELL /? _DEEPEN -/7 RECONDITION A7 DESTRUCTION /_7 <br /> " ( __TWO INSTALLAT N / / PUMP REPAIR / PUMP REPLACE / <br /> OtherL7 n q <br /> r <br /> DISTANCE -TO NEAREST: SEPTIC TANK &t7 - 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 Rotary Type of Grout - <br /> Disposal, Other -licher Information ' ' <br /> .-Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 5 <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP :REPAIR: / / State Work Done <br /> DES=TRUCTION 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.... The above <br /> information is true to.the•best of my-knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO UTING'AND A F AL INSPECTION. <br /> SIGNED TITLE <br /> r (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � . <br /> APPLICATION' ACCEPTED BY DATE ,5 <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION ItX - - DATE INSPECTION BY _/f/7 DATE 7-,2_L1 <br /> E H 1426 Rev. '1174 h/75 2M_, <br />