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10. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 / . G4)\ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/120-7 <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Named Phone <br /> Address' 1 City _ <br /> Contractor's Name ' <br /> License =hone <br /> TYPE OF WORK (Check): NEW WELL/ DEEPENS RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other j/7 <br /> DISTANCE TO NEAREST: SEPTIC TANK -e SEWER• LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 0 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF.WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation z Q <br /> Domestic/private" Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 17 . . ._ v <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 By: <br /> PUBO? INSTALLATION: Contractor <br /> - Type of Pump <br /> PUMP REPLACEMENT: f/_'---State Work Done <br /> PUM_ P .REPAIR: /_7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Laws and regulationsiof„the San Joaquin Local Health District i <br /> and the- State of California pertaining to or regulatiiig'well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well. I will furbish 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 CALL FORA GROUT INSPECTION <br /> PRIORL TO WLOUTJNG AN A Y&NAL INSPECTION. <br /> SIGNED _ TITLE <br /> ' DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I ` <br /> APPLICATION ACCEPTED BY DATE /�✓ Q j <br /> ADDITIONAL COMMENTS: <br /> PHASE JI GROUT INSPECTION PHA FINAL INSPECTION IIF <br /> k J <br /> INSPECTION BY DATE 1- 15 INSPECTION BY DATE t-9"S <br /> � E H 1426 Rev. 1-74 1-74 2M <br />