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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. 7 -t5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -Zo-74 <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 Local Health District. <br /> JOB ADDRESS/LOCATION / �)-i� CENSUS TRACT _ - <br /> Owner's Name Phone <br /> Address City 9-& <br /> L R <br /> Contractor's Name License #-2 7 Phone 34-e -e <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven. Gauge of CasingC <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �----� "— <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descrikl Matexifan oce' ure <br /> I hereby agree to comply 11- laws and regulations the San Joaquin Local Health District <br /> and the State of Califo a rtaining to or regulat' g 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 be of my knowledge and belief. I WILL CAI.,L FOR A GROUT INSPECTION <br /> PRIOR TO PROWITNP ANPIA FI IN CTION. <br /> SIGNED _ TITLE f <br /> PLAN 'ON-REVERSE SIDE) <br /> FOR DEPAR MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIODT ? <br /> INSPECTION .BY DATE INSPECTION BY r DATE <br /> E H 1426 Rev. 1-74 " <br /> 3/76 2M <br />