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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F70-F--'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 /> i <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/LOCATI N .� f4TRACT <br /> Owner's Name <br /> Phone, 6 <br /> Address <br /> )� d �J � City r <br /> Contractor's Name License Phonek'p <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ V RECONDITION I / DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR 14SI 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 bOMESTIC 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 /> r� Geophysical Surface Seal Installed By: <br /> 1 <br /> PUMP INSTALLATION: Contrae-tor j <br /> PUMP REPLACEMENT: . / / State Work Die <br /> PUMP .REPAIR: M' k <br /> / State Wo'k,,Done <br /> DES-TRUCTION OF WELL., Well Diameter Approximate Depth �..��,-" <br /> � 4y`•�Dd-scribe Material and Pocedure <br /> I hereby agree to .comply wig, all li*.-J'and reg lations of the San Joaquin Local Health District <br /> and the State of California rta ning io or r gulating well "construction. Within FIFTEEN DAYS <br /> -_ <br /> after completion of my work o ..— ew well,_I-�a 11 furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well ariz�-not fy--them before putting the .well in use. The above <br /> information i rue to the best of. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU2rjAG 4&D A FjgAL INSPE ION. <br /> SIGNED TITLE <br /> i3RAW i�L PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f { <br /> APPLICATION ACCEPTED BY DATE 2--2 - - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I,44/,FINAL INSPECTION- <br /> INSPECTION BY DATE INSPECTION BY DATE `ff''- <br />. E H 1426 Rev. 1-74 .. <br /> 3/76 2M <br />