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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , dl <br /> I <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 /> i(-7 5.9 7 nJ . 10 E ��c Es /�+J f ,�-�,,� _ r ry- 01 <br /> JOB ADDRESS/LOCATION �i✓ ° (?� SUS TRACT <br /> Owner's Name r Phone,jA/w Q <br /> Address City �sC � <br /> Contractor's Name !� ' LicenseW P h o n 34 �C{ � <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /L/---ISEEPEN -/ / RECONDITION /% DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 J <br /> Other <br /> CP <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 °moble Tool Dia, of Well Excavation <br /> Domestic/private i 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 B : <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work• Done <br /> PUMP .REPAIR: /_7 State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree td comply withalllaws 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 j <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION f <br /> PRIOR TO GROUTING A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW..PD6T PLAN ON REVERSE SIDE) ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I .I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE , <br /> R H 1426 Rev_ 1-74 3/76 2M <br />