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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TO&,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ] -/3d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /o'lk''7;7 <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/LOCATION CENSUS TRACT <br /> Owner's Name Phone ._) <br /> Address e City <br /> i Contractor's Name ` License Phan -j <br /> i <br /> TYPE OF WORK (Check) : NEW WELL. /—/ DERPEN '/? RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLA ION Ll PUMP PAIR /7 PUMP GEMENT /? <br /> Other /V <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES • PIT PRIVY <br /> SEWAGE DISPOSELD CESSPOOL/SEEPAGE PIT 0 R <br /> AL FI <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 Pr_otecion Rotary, Type of Grout <br /> Disposal Other Other Information <br /> kGeophysical Surface Seal Installed By: _ <br /> t - <br /> PUMP -INSTALLATION: Contractor <br /> Type of Pump 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 /> f <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 C4X FORA GROUT INSPECTION <br /> PRIOR TO G OUTING AUP AjYINAL PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHApE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION EY DATE L <br /> E H 1426" Rev. 1-7 „ 4/75 <br />