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SAN JOAQUIN LOCAL.sHEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 n <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / 7 <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate Is§ued ` �' <br /> (Complete In Triplicate) <br /> I 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 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 <br /> SO S CENSUS .TRACT <br /> Owner's Name &-"ajPhone ,�. 5/ <br /> Address City )�, <br /> Contractor's Name License X13 Phone' � � <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN/- RECONDITION /- DESTRUCTION / <br />' PUMP INSTAi,LATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br />! Other / / j <br />} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> y� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -• PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL�� d <br /> INTENDED USE TYPE OF WELL ` CONSTRUCTION SPECIFICATIONS" �f. <br /> Industria] 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 r <br /> Disposal Other . Othe r•' Iriformation <br /> Geophy's-i.cal Surface_Seal Installed By: <br /> PUMP INSTALLATION: .� Contrpctor � - >$ I—I.'_I.IrI-- -��I•,-•I <br /> a x <br /> f - Type of Pump. H.P. <br /> PUMP REPLACEMENT: / / .. State Work Done 1a <br /> PUMP ,.REPAIR: /7f/-State Work Done <br /> DES-TRUCTION 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 b1siridt <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION . <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED° TITLE J <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEP BY ,� WNW DATE J .7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL IN8PEC.TfON <br /> I' INSPECTION BYDATE INSPECTION BY DATE <br /> E H1426 Rev. 1-74 ; !f.7� 2M <br />