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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X11_ a�0� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a_% - 4 <br /> (Complete. In Triplicate) <br /> Application is liereby '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 /> ,pZr _ 030-ze <br /> JOB ADDRESS/LOCATION T CENSUS TRACT '! <br /> { <br /> Owner's Name <br /> Address City <br /> rContractor°s Name j, v License #`/137 3 Phone <br /> i <br /> TYPE OF`WORV(Check): NEW WELT, /? DEEPEN -1-7 RECONDITION /-7/ DESTRUCTION /7 <br /> t PUMP INSTALLATION / / PUMP REPAIR / / - PUMP REPLACEMENT A <br /> Other / 7 <br /> / <br /> DISTANCE TO 'NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' 1 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL t . 4Y CONSTRUCTION SPECIFICATIONS <br /> Industrial' t Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of !Well Casing <br /> Domestic/public r Driven Gauge ,of Casing <br /> - Irrigation Gravel Pack Depth of. Grout Seal i <br /> Cathodic Protection ,ti, Rotary Type of :Grout \ <br /> Disposal Other Other Information <br /> Geophysical .Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. ' <br /> Type of`Piimp H.P. <br /> pf - <br /> PUMP REPLACEMENT: /7 State Work Done <br /> f - - <br /> PUMP !ItEPAIIt a -ate"`--�J�" t`aW Work�Done Y` -_.�= <br /> ,SES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure E <br /> 'r <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 /> informationlis true to the-best-of-my knowledge and belief.i ' I WILL CALL FOR-A-GROUT INSPECTION <br /> PRIOR TO GROV13g AND A FAL INSPECTION. <br /> SIGNED YJ 1) TITLE <br /> DRAW PLOT-PLAN ON REVERSE SIDE <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED Y yrs DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE Z a <br /> E H 1426 Rev. 1-74 1-74 2M <br />