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' .SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POR;OF'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /f�6 <br /> (Complete In Triplicate) <br /> Application `ie 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 OrdinanceNo. 1862 and t es an gul.ations of the San Joaquin Local Health District. <br /> JOB ADDRE5S/L TON CENSUS TRACT <br /> Owner's Name hone <br /> Address a �1� City <br /> Contractor's Name i d <br /> License .Phone <br /> TYPE OF WORK Check): <br /> ( 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 t 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; • i Dia. of Well. Excavation // � <br /> Domestic/private Drilled Dia.fof Well Casing �r <br /> Domestic/publico 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 `B <br /> PUMP INSTALLATION: <br /> Contractor . . . <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: ., / / State Work Done <br /> PUMP '.REPAIR: NJ <br /> f /% 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 'construetion. Within FIFTEEN DAYS <br /> after.. completion of my waxlt on a new well, I,will .furnish : <br /> ' the,San Joaquin Local Health District a <br /> WELL DRILLERSREPORT•of the well and notify them before putting..the,_:we11. in.use-.:. The above <br /> information is true to the•best.of my.:knowledge and,,liel1ef. 'I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO G UTING AN A INAL P N. <br /> SIGNED TITLEJ' <br /> P ON REVERSE SIDE <br /> PHASE I <br /> D T USE ONLY <br /> APPLICATION ACCEPTED "� <br /> ADDITIONAL COMMENTS: DATE 4 ZZL f. <br /> PHASE 11 GROUT INSPECTION PHASE IIIFI <br /> NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />