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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X27 <br /> (Complete In Triplicate) <br /> Akffic&tion 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 Ru nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOC N �� CENSUS TRACT <br /> d <br /> Owner's Name Phone-';/-7 <br /> Address / � p City <br /> Contractors Name License1� hone17L2a' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT f <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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Q <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 Inf 5x.59ion <br /> Geophysical Surface Installed By: <br /> 4 PUMP INSTALLATION: Contractor <br /> Type of P H.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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTION. <br /> SIGNED16 � ltt TITLE <br /> D LOT PLAN ON REVERSE SIDE) T} <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' 4L <br /> PHASE II SP ION PH4W.JAIIANAL INSPECTIO <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> Eh 1426 Rev. 1-74 3/76 2M <br />