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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fokf.OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4 �/ <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 y (V, CENSUS TRACT <br /> Owner's Name 'T Qy,� .... Phone <br /> Address ) City <br /> Contractor's Name License Phtf -a 1 ! 3 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN -/7 RECONDITION /7 DESTRUCTION f � <br /> PUMP INSTALLATION /Gf�PUMP REPAIR /-7 PUMP REPLACEMENT 17 <br /> Other J% <br /> DISTANCE TO NEAREST: SEPTIC TANK /an r SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOQSEEPAGE 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 /> l—Domestic/private t/brilled 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 H <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 1r 'REPAIR: /7 State Work Done <br /> jRUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe jiaterial and Procedure, r <br /> I hereby agree to comply with all lawslarta 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 GPIOUTING OD A FI AL INSP CTION. <br /> SIGNED r , TITLE _ 2 U2 0 <br /> (DRAW PLOT PT,AN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> I E H 1426 Rev. 1-74 1-74 2M <br />