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s fSAN JOAQUIN`�LOCAL HEALTH DISTRICT <br /> FOPSrO FICE USEE: 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 /.-ase-75- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San .Joaquin Local Health Distti:ct 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 off he <br /> San Joaquin Local Health District. <br /> JOB ADDRESS LOCATIO <br /> CENSUS TRACT <br /> TRACT/ <br /> Owner's N Phomei. ti'i a67 <br /> Address / City <br /> _ s <br /> Contractor's Name Ob License � ,�phone <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN '/? RECONDITION /'7 DESTRUCTION %f <br /> PUMP INSTALLATION / -/ PUMP REPAIR /_7 PUMP REPLACEMENT <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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: %/ State Work Done , <br /> PUMP'`REPAIR: L� State Work Done <br /> ES;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-best-of my-knowledge and belief. I WILL'CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED , TITLE ,cal�crl <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `---1 � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I I/F NAL INSPECTIO <br /> INSPECTION BY DATE LINSPECTION BY DATE <br /> µE H 1426 <br /> Rev. 1-74 - 1-74 2M <br />