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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE. 1601 E. Hazelton kve. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r APPLICATION"F'Oft WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is` Aereby 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 incompliance with San Joaquin <br /> County Ordinance No. 1�86J2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone 3 > 19 2� .� <br /> Address <br /> 4 CityT d Y <br /> Contractor's Name <br />- TYPE OF WORK (Check) : NEW WELL DEEPEN_ r,/�— RECONDITION /_/ DESTRUCTION /_7PUMP INSTALLATION / UMP REPAIR / / PUMP"REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> -PROPERTY LINE - PRIVATE- DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL N, <br /> CONSTRUCTION SPECIFICATIONS <br /> f ` <br /> Industrial , _ able Tool F Dia. <br /> of Well Excavation /• <br /> Domestic/private Drilled �'' Dia. of Well Casing <br /> Domestic/public Driven „`� lGauge of Casing ' <br />�Irrigation Gravel Pack"l Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> —� -- <br /> �` � <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ;�.� ���� <br /> Type of Pump ni t. H.P. 1 <br /> PUMP REPLACEMENT: /�/ State WorkiDone t <br /> J tr <br /> PUMP .REPAIR "�St� <br /> • /""/ " a:te Work Done"` <br /> DESTRUCTION OF WELL: Well Diameter Approximate' Depth <br /> Describe Material and Procedures . - <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 J <br /> after- completion of my work on a new we'll -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 CALL FOR A GROUT INSPECTION s <br /> PRIOR TO GROUTI G A FINAL SPECTION. ` G <br /> SIGNED r TITLE I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY,!�jdll - Ole �.��_ <br /> ADDITIONAL COMMENTS: ; <br /> -- --- •-�-...�_- DATE <br /> PHASE II GROUT INSPECTION ,• PHASE WI/FINAL INSPECTION <br /> INSPECTION BYDATE s ` INSPECTION BY <br /> DATE <br />.�E H 1426 Rev. 1-74 1f77 2M <br />