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-7 2,/ U -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE'•OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z -0 <br /> THIS PERMIT EXPIRES 1 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. 1.$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> j � <br /> Address - Cit <br /> Contractor's NameLicense # Phone 4 `¢ <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION % PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LIES �IT PRIVY 6' <br /> SEWAGE DISPOSAL FIELD S _CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL J PUBLIC DOMESTIC WELL '--- ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Inastrial Cable Tool Dia. of Well Excavation (/ <br /> omestic/private Drilled Dia. of Well Casing �' a <br /> Domestic/public Dr' en Gauge of Casing 1;2— <br /> Irrigation ra 1 Pack Depth of Grout Sea.; <br /> Cathodic Protection &-- Rotary Type of Grout ilr� <br /> _Disposal Other Other Information 6 <br /> Geophysical Surface Seal Installed B I <br /> PUMP-INSTALLATION: Contractor / <br /> Type of Pump 1 '6 WAIK _T tHrP <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desc lbe 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 D LLERS REPORT of the well and -notify them before putting the .well in use. The above <br /> informa n is true to the best o owledge and belief. 1 WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A FIN S N. <br /> SIG TITLE a <br /> 'i T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I <br /> APPLICATION ACCEPTED BY 5 DATE J 7 <br /> ADDITIONAL COMMENTS: <br /> WM11 GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE - b-�6 INSPECTION BY DATE <br /> F 1 i. .. T Kr 2M <br /> E H 1426 Rev. 1-74 <br />