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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEj.OFFICE USE: 1601 E. Hazelton Ave. , •Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �s Z/4�.d <br /> * r r <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 Oidinance No. 1862 and the Rules and Regulations of .the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �e, NSU TRACT <br /> R • <br /> 'Owner's Name eC- Phone <br /> Address .► <br /> City <br /> Contractor's Name License # Phone <br /> F <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN 17 RECONDITION /T7 DESTRUCTION <br /> PUMP INSTALLATION -7 PUMP REPAIR /-J 7 <br /> PUMP REPLACEMENT / <br /> Other-_/�7 <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES SPOOL/SEEPAGE PIT s LLL OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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: j/ / State Work Done <br /> PUMPREPAIR: /7 State Work Done <br /> 2ESmRUCTION OF WELL: Well Diameter Vii/ Approximate Depth <br /> Describe Material and Procedure 4 <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 /> f information is true to the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ROUTING AND A FINAL INSPE ION. <br /> SIGNED ¢' TITLE�- i <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> . � PHASE II'GROUT INSPECTION PHAS I FIWL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E.H 1426 <br /> Rev'. 1-74f <br /> 1-74 2M <br />