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71 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•OFFICE USE: <br /> 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 <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' CENSUS TRACT <br /> Owner's Name _ fid c � r%' o Phone % ` er g <br /> --, . <br /> Address � � /� f� ,��'� City <br /> Contractor's Name %�a�� �7- License PhoneW141'-A-7-0 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN isr RECONDITION /'7 DESTRUCTION r7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP PLACEMENT /7 <br /> Other L7 <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 (A <br /> Industrial 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 <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: /7 State Work Done _ <br /> PES-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 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING A YINAD INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHME Alk"INAAINSPECTIO <br /> INSPECTION BY DATE INSPECTIONB ATE <br /> i E H 1426 Rev. 1-74 1-74 2M <br />