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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;l'_�iyjJo <br /> THISPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-,22--;K <br /> (Complete In Triplicate) 1 <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 Phone <br /> Address D City <br /> Contractor's Name C.& ��� "� License Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /—T <br /> PUMP INSTALLATION ;PUMP REPAIR/ / PUMP REPLACEMENT /-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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 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 ` = i ':Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a/ <br /> Type. of Pump IF H.P. ' <br /> PUMP REPLACEMENT: / J 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 C FOR A GROUT INSPECTION <br /> PRIOR TO G UTING A FINAL I1,14PECTION. <br /> SIGNED TITLE - <br /> DRAW PLT PLAN ON RE TE SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> .PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 - <br /> ADDITIONAL COMMENTS: <br /> PHASE II G)=7 SPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY / ATE <br /> E H 1426 _ 3/76 2M <br /> Rev. 1-,74 <br />