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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh;OFFICE USE: C� 1601 E. Hazelton Ave. , Stockton, Calif. <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 ��/-72 <br /> (Complete In Triplicate) . <br /> Application is hereby made to the San Joaquin Local Health District for a. permi.t to construct <br /> and/or install the work herein described. This application .ie' made in compliance with San Joaquin, <br /> 6 County Ordinance No. 1861 'and the Rules and Regulations of 'the. San;:JoaQuin Local Health District. <br /> JOB ADDRESS/LOCATION t <br /> CENSUS TRACT <br /> Owner's Named . <br /> Phone �( <br /> Address <br /> City x o <br /> Contractor's Na � 4 A9 - License #/73326 Phone <br /> TYPE OF WORK (Check): NEW WELL "f-7 DEEPEN/? RECONDITION f-7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR/? PUMP REPLACEMENT J f <br /> Other /% <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHEK <br /> 11. 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 /> Domestic/private Drilled Dia. rof .Well Casing _ s <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 Inbtalled B ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. '► <br /> PUMP REPLACEMENT / / State Work Done ^• <br /> PUMP ,REPAIR: , /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 -dell and notify them before putting.-the.-well in -use.... The above <br /> information is true to the-beat-of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED� TITLE © , <br /> (DRAW PLOT PLAN ON REVERSE SIDE�__. <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE ' ` <br /> PHASE 11 GROUT INSPECTION P E I INSPECTION/ <br /> INSPECTION BY DATE INSPECTION BY DATE 2 , <br /> E H 1416 Rev. 1-74 rr - 1./7t OU <br />