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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: +� ` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> E/ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit'No. .Zti� <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 /> I County Ordinance No. 1862 and the Rules <br /> rs( and Regulations of the San Joaquin Local Health. Distriet. <br /> JOB ADDRESS/LOCATION /J— ? 0 /cam .� CENSUS TRACT <br />' <br /> Owner's Name Phone�/ <br /> Address �.� �'� �"'-`�`�'�" City 2y <br /> License Phoned' <br /> Contractor's Name -- <br /> TYPE OF WORK (Check): NEW WELL/ / ,DEEPEN 17 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT JIT <br /> Other <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 TYPE OF. WELIr-- CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable"Tool Dia. of Well Excavation (A <br /> Domestic/private Drilledf� Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C"A <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 By: <br /> PUMP INSTALLATION:------- -Contrac-tor <br /> Type of Pump H.P. ff <br /> { FUME REPLACEMENT /% State<Work Donee <br /> PUMP .REPAIR: / / State'Work Done <br /> DES-TRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> k 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 best of my.-knowledge and belief. I WILL CA1,10FOR A GROUT INSPECTION <br /> PRIOR TO WOUTING AIQ A)FINa INSPE ION. �y <br /> SIGNED TITLE <br /> DRAW PL T' PLAN ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY cif' DATE <br /> ., E H 1426 Rev. 1-74$ 3/76 2M <br /> ea. <br />