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SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> F <br /> k <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 3 ,,;,;x-j� <br /> M (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 ` CENSUS TRACT <br /> Owner's Name Phone ' <br /> Address �® LIZ6&:�_40) <br /> City Y <br /> Contractor's Name ' License <br /> Phone / <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/? RECONDITION /7 DESTRUCTION /—f <br /> PUMP INSTALLATION/4r/'rPUMP REPAIR/_7 PUMP REPLACEMENT % f <br /> Other j/7 -- <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 DOME5TIC WELL (v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS VI <br /> Industrial Cable Tool Dia. of Well Excavation " I <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 <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP :REPAIR: /_ .State Work Don <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 /> 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 .af. my..knowledge and belief. I WILL CALL FOR A GROUT. INSPECTION <br /> PRIOR TO GROUTTWn AND A FINAL I SPECTION. . <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I - _'— <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE � � =7� <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHA YII INAL INSPECTION <br /> INSPECTION BY -- DATE INSPECTION BY 6a DATE <br /> r r <br /> E H 1426 Rev. 1-74 <br />