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JZ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO :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 1,_106,-"o <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 Joaquii <br /> County Ordinaiice No.� 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONZA 6. CENSUS TRACT <br /> Owner's Name Phone ' <br /> Address <br /> City <br /> Contractor's Name - Lcense <br /> ePhone <br /> TYPE OF WORK (Check): NEW WELL.,/77-'DEEPEN -4-7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION Zz:,,4 � REPAIR/� PUMP REPLACEMENT /7 + <br /> Other E7 -- <br /> + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL�� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> InAustrial e Tool Dia. of Well Excavation �+c ' <br /> ome s tic/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 /> ormation <br /> j Geophysical f�., -- 1 <br /> Surface Seal Installed 'B <br /> PUMP `INSTALLATION: ` + <br /> Contractor <br /> t -Type-of_4ump <br /> H.P <br /> f PUMP REPLACEMENT; State Work Done.:_ <br /> f PUMP ,REPAIR: /7 .State Work Done 4 ( {mY <br /> j l <br /> DESTRUCTION OF WELL: Well Diameter 1 '` . <br />€ 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 "constJoaquin. Within FIFTEEN DAYS <br /> after completion of my work an a new iae3l I will famish 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 /> iinformation is true to the-best-of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN AND FINAL I E <br /> J SIGNED <br /> {DRAW PLOT PLAN ON REVERSETLE SIDE <br /> PHASE T <br /> FOR DEPARTMENT' USE ONLY <br /> .. <br /> APPLICATION ACCEPTED BYC , d3 <br /> ADDITIONAL COMETS: . ^ <br /> PHASE 1I UT INSPECTI N j PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �. ( INSPECTION BY ,' DATE /7 <br /> -E H-1425 Rev. 1-74 <br />