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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFirOFFICE USE: 1b01 E. . Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (209) 455=5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit_ No. <br /> THIS PERMIT EXPIRES 1' YEAR-FROM DATE ISSUED Date Issued -/S-7,5-- <br /> (Complete :In Triplicate).- <br /> Application is hereby made to the San Joaquin.Local Health.District for a permit to construct <br /> anti/or install the work herein-:.described. This application is;made in.-compliance with San Joaquin <br /> .County Ordinance No. 11862 and the Rules and Regulations. of the San .Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> !CENSUS TRACT � <br /> Owner's Name Y Phone <br /> j <br /> Address City <br /> e <br /> Contractor's Name License # Phone ;W-fiO <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN/_7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR 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 AlizN <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled 4 Dia. of Well- Casing <br /> Domestic/public Driven '��7 Gau.ge_of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal ' Other Other Information <br /> _�. <br /> Geophysical` Surface Seal Installed By:,,._, <br /> PUMP INSTALLATION: Contractor • ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'PUMP':REPAIR; - �--�„ _ <br /> —Stata FWork`Done " '-'-,- �^ `� -�•.=�� .-'- <br /> 6 <br /> y .. a <br /> ES'PRUCTION 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �y TITLE <br /> (DRAW PLOT PLAN ON. REVERSE SIDE - <br /> - - ---- ' FOR DEPARTMENT USE ONLY — <br /> PHASE I. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 . <br /> Rev. 1-74 T 1-74 2M <br />