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. � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> /" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOE OFFICE USE: i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT Permit No. zG,J '! <br /> THIS PERMIT EXPIRES.I 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS <br /> SUS TRACT <br /> Phone <br /> Owner' 's Name <br /> City <br /> Address <br /> License <br /> Contractors Name'—' <br /> .. L <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION /� DESTRUCTION /� r <br /> PUMP INST/LLLATION ' / PUMP REPAIR /!/ PUMP REPLACEMENT /� <br /> Other / / <br /> IE <br /> DISTANCE TO NEAREST: SEPTIC TAN �SAL <br /> SEWER LINES PIT PRIVY <br /> xSEEPAGE PIT OTHER <br /> * SEWAGE DISPFIELD / ,,, <br /> PROPERTY LINE -- PRIVATE DOMESTIC WEL PUBLIC DOMESTIC WELL <br /> if— <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i 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 Rotary Type of Grout <br /> Disposal other OtherlInformation ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.F. <br /> Type of Pump <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: I State Work Done/ ,,,.. .,. --- <br /> rApproximate L <br /> DESTRUCTION OF WELL: Well Diameter 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 /> I will furnish the San Joaquin Local Health District a <br /> after completion of my work on a new well, <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 <br /> FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI TLE O <br /> SIGNED :P LAN 'QN RE LRSE SIDE) , <br /> FO DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CO;PRASE <br /> TS: <br /> I OUT INSP TIO PHASE II / INAL INSPECTION <br /> INSPECTION BY <br /> DATE 6 INSPECTION BY DATE 7 <br /> .. 3/?6 2M <br /> E H 1426 Rev. 1-74 - <br />