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F <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. <br /> _. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> !50 :-. Sc_.dc p� /�� , '[ I (Complete In Triplicate) �r0, C1 F3-2_1,o E <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 /> i! <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ - Phone <br /> Address 3 <br /> City <br /> Contractor's Name _ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /7 4 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /? Z <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 C� <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 Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 70 <br /> • i <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 /> 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-ithe 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 A GROUT INSPECTION <br /> PRIOR TO GROU N24D FI AL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PI' T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY AlY DATE <br /> 3/7b 2M <br /> E H 1426 Rev. 1-74 <br />