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g SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t FOE OFFICE USE: <br /> 1603. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. � T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date, Issued(7� . <br /> f (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 /> JOB ADDRESS/LOCATION .3CI !p <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Named License # �'6a°� Phone �4L <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN -/—/ RECONDITION /-f DESTRUCTION /7 <br /> PUMP INSTALLATION /- PUMP REPAIR/-7PUMP REPLACEMENT /? <br /> j Other <br /> 1� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DI5POSAL 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 ll"� <br /> Cathodic Protection Rotary Type of Grout F <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump let, H.P. <br /> PUMP REPLACEMENT / ,/ State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION 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 Calif.ornia.'.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 my knowledge and belief. I WILL L FOR A GROUT INSPECTI <br /> PRIOR TOG UTING AN FINAL- INSP CTION. <br /> SIGNEDFIT <br /> TITLE { <br /> DRAW PL T PLAN ON REVERSE SIDe�-µ-,,- „ f. <br /> PHASE I """""^- FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE � <br /> ADDITIONAL COMMENTS <br /> G <br /> PHASE II GROUT SPECTION EH, <br /> E III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY = DATE -rte 7 S- <br /> E <br /> E H 1426 Rev. 1=74 ' 3/76 2M i <br />