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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 F. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: (209) 466-6781_ - <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, oy le'l <br /> 7,1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. /�G <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 /> I a <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name r .� Phone <br /> Address City <br /> Contractor`'s Name - ®License #,70 Phone <br /> TYPE OF WORK (Check) : , NEW WELL/ DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION Z PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK . c' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER } <br /> PROPERTY LINEWRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL ; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 41 <br /> Domestic/private Drilled Dia. of Well Casing (� <br /> Domestic/public Driven Gauge of Casing 2— <br /> Irrigation Gravel Pack Depth of Grout Seal ? f <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: / / 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 taining to or regulating well 'construction. Within FIFTEEN DAYS x <br /> after completion ,o_f my w on anew well, ,I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT the well and notify them before putting the..well in use. The above <br /> information is t ue o the best- f y kxn5ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AL INP <If. <br /> SIGNED ,,--� TITLE <br /> DRAW FTS T PLAN 'ON REVERSE SID I: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED" BY_ .LL � - 1,4zi DATE 7 <br /> ADDITIONAL COMMENTS': ., <br /> PHASE II GROUT INSPECTIO <br /> INSPECTION BYDA INSPECTION ,BY DATE <br /> E H 1426 v. 1-74 <br /> 3/76 . 2M <br />