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SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J74J <br /> THIS PERMIT EXPIRES l 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 andRe mations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 c ' 4 CENSUS TRACT <br /> / <br /> Owner's Na �J r�� F Phone <br /> Address 440,4, City. <br /> Contractor's Name , * License Phone <br /> TYPE OF WORK (Check) : NEW WELL 'j/ DEEPEN '/ / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMEWF /7 <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 L CONSTRUCTION SPECIF C TIONS -v <br /> Industrial able Tool Dia. of Well Excavation <br /> mestic/private Drilled Dia. of Well Casing �j <br /> Domestic/public Driven Gauge of Casing (,d <br /> _j___Z-Trrigation 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: Contractors r <br /> Type of Pump P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 k9st of- my knowledge and belief. T WILL Qk.LL FOR A GROUT INSPECTION <br /> PRIOR TO GR I G An A FI§A IN$ PE&ION. <br /> SIGHED A J. TITLE • <br /> (DRAW P : 'T PLAN ON REVERSE SIDE tl; <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY �• DATE �� INSPECTION BY (?"I- DATE , I�r <br /> E H 1426 Rev. 1-74 -- _ <br />