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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk.OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a?-4 -I <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 Sap Joaquin <br /> County Ordinance No. 1862 nd the Rule d R ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LO <br /> CENSUS TRACT <br /> Owner's Name <br /> Address Ci L9G <br /> Contractor's Name Licensa4* �Phoni[&�% � <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 W LL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2n, <br /> Domestic/private Drilled Dia. of Well Casing Z <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Al <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . . . . <br /> PUMP REPLACEMENT: ( State Wor <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 bistrict <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 besit .ofjmy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL-INSPECTION. <br /> SIGNED. _ , TITLE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ATA7 , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT11NSPECTION . PHASEI JrIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ' 1/77 _ 214 <br /> J <br />