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.. J. <br /> C,6 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. s <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6. V,r4•L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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 CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City . <br /> Contractor's Name <br /> License Phone . . <br /> TYPE OF WORK (Check): NEW WELLDEEPEN ' 7 RECONDITION /7 DESTRUCTION f7PUMP INST LLATION / PUMP REPAIR/-7 PUMP REPLACEMENT <br /> Other j/7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP00L/SEEPAGE PIT OTHER 1I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial K 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:' <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: f_1 State Work Done . . . . <br /> DES.TRUCTIO_N OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Y 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 Chem 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 GAWTING AND A F INSPECTION. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE. ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> . <br /> ADDITIONAL COMMENTS: dd <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTI2 <br /> INSPECTION BY DATE INSPECTION BY 4�'_P-s5T- DATE 2 <br />- E H 1426 Rev. 1-74 4/75 2M <br />