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SAN JOAQUIN LOCAL.-HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. - ld . <br /> N. Telephone : (209) 466--6781 <br /> JQ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> DEC 28 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / <br /> (Complete In Triplicate) I <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 �Q CENSUS TRACT <br /> �. <br /> Owner's Name Phone <br /> Address 4400 City <br /> Contractor's Name w License �� � �g/ Phon 33 Y <br /> TYPE OF WORK (Check) : NEW{-WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INST CATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAG_E. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial y Cable Tool Dia. of Well Excavation <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 v _Type- of Grout` <br /> Disposal Other *; _Other�Infordation <br />-Geophysical _ <br /> -. Surface Sealdlnstalled B <br /> ..c � r. <br /> PUMP INSTALLATION: Contractor ci <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: '- ` 1 i <br /> S tate' Work Done <br /> DES-TRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure �;,.•- " - <br /> I hereby agree to comply with a11' laws and regulat.i..-ons"of.. theySan Joaquin Local Health District <br /> and the State of California. pertaining to or regulat' n-g`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 .REFORT 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 G UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED�.BY DATE r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 117.7 2M <br />