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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3rI p <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued (Q7 <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 oc,�l HealthD tric . <br /> JOB ADDRESS/LOCATION CENSUS TRACT " <br /> Owner's Name Phone v � <br /> Address / City <br /> + icense �F� Phone /�y � <br /> Contractor's Name <br /> r - <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPE '/ / RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION jq 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 /> 4 <br /> PROPERTY LINE "'P"RIVATE 'DOME�S'TIC WELL �a =.PUBLIC AOMESTIC.,WELL <br /> " INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> a <br /> D6mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing \_ <br /> Irrigation Gravel Pack Depth of Grout Seal �h <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical f;' Surface Seal Installed B <br /> PUMP INSTALLATION: Contracto <br /> vP <br /> Type of Pump . H' <br /> -,. .. <br /> PUMP REPLACEMENT: / / State) War Done <br /> PUMP -.REPAIR: / / Stafe Work Done <br /> jDES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> k <br /> Describe -Material and Procedure <br /> r � <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 kof my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> ,PRIOR TOUTING FIN INS., ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 3 <br /> FOR DEPARTMENT USE ONLY <br /> .PHASE I <br /> 1APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTION PHASE III IN INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> _ 1777 _ 2M <br /> R. H 1426 RPv. 1--74 <br />