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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 0,041 <br /> THIS PERMIT EXPIRES l 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/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City , <br /> Contractor's Name ,,,. License # 'G phone cf. ,y 6 <br /> TYPE OF WORK (Check): NEW WELL/ f DEEPEN '17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/--PUMP REPAIR '/-C� 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 v <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 Other Information:, <br /> Geophysical Surface Seal_Installed 'BY: <br /> PUMP INSTALLATION: Contractor . �„�... <br /> Type of Pump ` H.P. ! <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPAIR: / / State Work Done tJ r <br /> ,DESTRUCTION-OF WELL: Well Diameter A 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. `kno le g laud b ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPELtION. <br /> SIGNEDv/ TLE _ <br /> (D W LOT-PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY )f DATE. '�j' <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE L/2-2- <br /> E H 1426 Rev. 1-74 r 4/75 2M <br />