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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE 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 /> 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 /> w <br /> JOB ADDRESS/LOCATION 0CENSUS TRACT <br /> Owner's Name Phone <br /> Address City 1 <br /> Contractor's Name ! -79 License �� Phone <br /> �K <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN / / RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATIO / PUMP REPAIR / UMP REPLACEMENT /- <br /> N R/ <br /> 0ther / / CJ / a w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ,I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation T /,r` <br /> Domestic/private ; Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation 1; Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal f"f Other Other Information <br /> Geophysical �I. Surface. Seal Installed BY: <br /> PUMP INSTALLATION: Contractor d �� <br /> Type of Pump ,� r �.��- W H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 11 <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> P 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 REPORTa e well and notify them before putting the -well in use. The above <br /> information is` tru o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AL I U_ e `� <br /> SIGNED TITLE <br /> W P ; T AN 'ON REVERSE SIDE) is ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> . APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: y. `' , <br /> PHASE If--G RPHASE III/FINAL INSPECT ON <br /> INSPECTION BY" DATE y 'INSPECTION BY �(� _ DATE I <br /> 3/76 . 2M <br /> E .H 1426 Rev. :1-74 <br />