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N01 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR1OFFICE USE: jld 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 .3-/wl ✓� <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��hie es and Regulations of> the San Joaquin Local Health Districi. <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner v s Name �� � /vas Phone a <br /> Address City �,✓ <br /> Contractor's Name License #.,2WZ�Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN -7 RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION PUMP REPAIR 1-7 PUMP REPLACEMENT-0 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL yIELD,/4D'` CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE W PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.of Well Excavation 1P� <br /> Domestic/private Drilled Dia. of Well Casing - <br /> Domestic/public-- Driven Gaugeof Casing <br /> Irrigation Gravel Pack Depth ce <br /> of Grout Seal Sea— i` / <br /> Cathodic Protection Rotary Type of Grout v� <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 �A <br /> PUMP :REPAIR: /7 State Work Done <br /> ,RES 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 REPO o,0 the well and notify them before puttingthe..well in use.. The above <br /> information is ue of m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIO A F AL SP ON <br /> SIGNED �. TITLE <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 PHASE III F AL INSEEGTiON <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> t._ <br /> H 1426 Rev. 1-74 1-74 2M <br />