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Cn. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS,,OF ICE USE. 1601 E. Hazelton Ave. , Stockton, Calif,. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued` <br /> (Complete In.Trplicate) <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 ___ a l � /'✓ 2�Q CENSUS TRACT <br /> Owner"s Name /�-rrrl Phone <br /> AddressA f�`���_� � City <br /> Contractor's Name �, License #/ --Phone Y7 --bl <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /7 ' j <br /> 'DESTRUCTION f <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 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 V <br /> -Geophysical <br /> . , Surface Seal Installed Bvi <br /> PUMP INSTALLATION: Contract <br /> Type. of Pump - H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP (REPAIR: /T/ State Work Done . ' <br /> ,DES•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 know ed �h&-belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T.2--GR TING AND A FINAL PE I <br /> SIGNS (TLE �- <br /> (D LOT P :2�w 4 <br /> LAN ON R'SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY DATE��'��� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE I SPECTION BY DATE/ <br /> E H 1426 Rev. 1-74 17K 7M <br />