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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL 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 />' JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone ?v; <br /> or <br /> C!—d } : City <br /> Address pp <br /> k Contractor's Name License #.1f./Gj7(,Phoned,23 <br /> t i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /' / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / 7PUMP_,.REPAIR / / PUMP REPLACEMENT <br /> Other <br /> a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r 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 j- Cable--Tool Dia, of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing q <br /> Domestic/public - rDriven Gauge of Casing d <br /> Irrigation K Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ') _ . . Type,-of Pump H.P. <br /> PUMP REPLACEMENT: ! / `State Work Dane <br /> PUMP REPAIR: / / State Work Done <br /> r <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 hest of my knowledge and belief. I WILL CP4 FOR A GROUT INSPECTIO <br /> PRIOR TO gROUTING MD aINtL INSPECTION. <br /> SIGNED TITLE LC' 4 <br /> ,17 (DRAW- PLOT PLAN 'ON RE FRSE SIDE i... <br /> F R-DEPARTMENT USE ONLY <br /> PHASE I DATE�Q <br /> # APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE I � ROUT INSPECTION PHAS�jLk6IJJL�*INAL NSPECTION <br /> f INSPECTION BY DATE INSPECTION BY ATE ..-�� <br /> x <br /> ti <br /> 3 3/76 2M <br /> t E H 1426 Rev. 1-74 <br />