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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. v <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No'. <br /> F <br /> 1 �/!^JjJ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ` <br /> {Complete In Triplicate} <br /> Application is e .eby 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.Ordlnance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION p CENSUS TRACT <br /> Owner's Name Phone k3g <br /> Address City <br /> Contractor's Name LicensePhone <br /> .TYPE,OF WORK,(Check) :-_NEW WELk,- _- -DEEPEN/ / -RECONDITION / /'- DESTRUCTION / <br /> - - PUMP`:INSTAL1ATION.•/- PUMP.rUPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE ,TO NEAREST: SEPTIC TANK Q,j SEWER LINES PIT PRIVY <br /> 1 <br /> SEWAGE DISPOSAL 'FIELD CESSPOOL/SEEPAGE PIT ' OTHER <br /> PROPERTY LINES RIVATE DOMESTIC WELI&jQQ_ PUBLIC-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial /-" . Cable Tool Dia.�of Well Excavation y 'I <br /> Domestic/private Drilled Dia;- of Well Casing , _ � <br /> Domestic/public Driven Gauge of Casing p <br /> _ :Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �) <br /> Disposal Other Other Information -�- <br /> Geophysical t Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �G- }`i H.P. $" <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP I REPAIR: <br /> � _/_/State Work Done , <br /> DESTRUCTION OF WELL: Well Diameters 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 st my n ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T G A FINb I E 0 , <br /> SIGNED TITLE <br /> ! ( RAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE .I <br /> APPLICATION ACCEPTED BYDATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION PHASE /FIN IN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Ole <br /> E H 1426 Rev. 1-74 2M <br />