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SAN JOAQUIN LOCAL HEALTH DISTRICT <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.� p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1-z>- �y <br /> (complete In Triplicate) 7 <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 PPlication is made in compliance with San Joa uin <br /> County Ordinance Noe <br /> J^u / of the San Joaquin Local Health Dist ct. <br /> JOB ADDRESS/LOCATIO /`�>,- <br /> "�`� � CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name / t <br /> License #/�� Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN17 <br /> PUMP INSTALLATION Q�' PUMP, REPAIR —/—P/P DESTRUCTION <br /> Other / J // UMP REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Gable Tool Dia. of Well Excavation <br /> Domestic/Domestic/private Drilled Dia. of Well Casing <br /> Irrigation <br /> 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 7j - <br /> H.P.H.P. <br /> PUMP REPLACEMENT: � State Work Done } <br /> PUMA' :REPAIR: <br /> L77 _ <br /> State Work Done-�- --- - _ <br /> PE&TTRUCTIO_N OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth } <br /> I hereby agree to comply with ail 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-best of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTIO <br /> PRIOR TO GROUT G A FINAL INSPECTION, <br /> SIGNED G� <br /> TITLE d 's`-s <br /> DRAW PLOT PLAN ON REVERSE SIDE <br />_PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE OUT I SPECTION ' . <br /> 'ION BY DATE PHASE IIT FINAL INSPECTION :.; <br /> INSPECTION. BY DATE ; ✓J <br /> 26 Rev. -1-»74 <br /> 1-74 u <br />