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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 /> LT A APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No..,7,L_ g9.S6')O <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 th n Joaquin Local Health District. <br /> 4 JOB ADDRESS/LOCATION � � CENSUS TRACT <br /> Owner's NamePh6ne� <br /> Address <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT <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 Cable Tool Dia. of Well Excavation V <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: ContractozA41j, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ..;-,-a <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Wel]. 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 t the best of my knowledge and belief. I WILL CAL FOR A GROUT INSPECTION <br /> PRIOR TO G TING A FI ALNS ECT ION. % <br /> SIGNED TITLE Z G <br /> D W PUT PLAN ON REVERSE SIDE) ; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -71' <br /> ADDITIONAL COMMENTS: <br /> PHASE 14 ,GROUT INSPECTION PHASE W/FIN4 INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - - -7,4/ <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />