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�Q4) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 0�` 1601_ E. Hazelton Ave. ; .Stockton, Calif. <br /> - <br /> Telephone: (209) 466--67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR .FROM DATE ISSUED Date Issued �/_ J7 <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 . 1 64401 <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> &�ir-/��Vphone <br /> Owner's Name <br /> City �ClD� <br /> Address <br /> Contractor's Name License -t. wphone <br /> t .. <br /> TYPE OF WORK (Check); NEW WELL -/ / DEEPEN '/ / RECONDITION '/_/ DESTRUCTION /7 <br /> ,PUMP INSTALLATION / / PUMP REPAIRr/ (/ 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Y Domestic/public•-._-_ Driven Gauge of Casing <br /> Irrigation Gravel Pack"= '- 'Depth of Grout Seal <br /> Cathodic Protection Rotary. . k Type of Grout <br /> Disposal Other � Other -Infbrmation <br /> Geophysical„ _ - Y Surface Seal. Installed B <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump <br /> PUMP REPLACEMENT: / / , State Work Done " <br /> PUMP REPAIR: State Work Done <br /> 1 <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 California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> F after completion of my work on a new well, I will furnish the San Joaquin Local• Health District a <br /> E WELL DRILLERS REPORT of the well and notify them before putting the well in use. . The above <br /> information rue to the best of my knowledge and belief. I WILL CAL FOR A GROUT INSPECTION <br /> s PRIOR TO G <br /> UTI$G AND A FIN INSPECTION. _ <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��/{��fff DATE <br /> -4�4A* <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSP ON PHAS III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. ,-IX-74 <br />