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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 CONSTRUCTION OR PUMP PERMIT Permit No. <br /> l THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In 'Triplicate) r <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. "$ and the Rules and Regulations of the San Joaquin Local Health District, <br /> � O � I CENSUS TRACT <br /> JOB ADDRESS/jc TION sed <br /> �- Phone <br /> owner's Name <br /> City <br /> Address _ <br /> Contractor's Name License_ <br /> TYPE OF WORK (Check) : NEW WELL fi;�r DEEPEN `/ / RECONDITION_/� DESTRUCTION /7 <br /> 7 <br /> � PUMP INSTALLATION/�/ PUMP REPAIR / / PUMP REPLACEMENT 1 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELT. CONSTRiTCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Q <br /> - Domestic/private Drilled Dia. of Well Casing �' G <br /> Domestic/public Driven Gauge of Casing d <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary , Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> ;. Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> } State Work Done <br /> PUMP .REPAIR� rt I I <br /> f i <br /> DES•TRUCTION 'OF WELL: We11 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 wor on anew well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT the well and notify them before putting the -well in use. The above <br /> . <br /> informationlis true o the y Knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 7 PRIOR TOTI INAL N N. TITLE <br /> SIGNED <br /> If W Pi. T PLAN ON REVERSE SIDE <br /> E !�t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE / 7 <br /> ! f <br /> APPLICATION ACCEPTE <br /> ADDITIONAL CO Tp5 INSPECTION <br /> p OUT INSPEC 0 INSPECTION BY DATE <br /> INSPECTION B DATE . <br /> (� 3/76 2M <br /> E H 14 Rev. 1-74, <br />