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,�}ry SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FOF.OFFICE USE: a 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209 466-6781 } <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 <br /> CENSUS TRACT <br /> Owner's Name Phone 9311— Z <br /> Address C City " <br /> t <br /> Contractor's Name .,tiZLicense # Phone ' <br /> i � <br /> t <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN -1-1 RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION/—/ PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / 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 '�T _'PUBLIC DOMESTIMATIONS <br /> INTENDED USE 4 TYPE OF WELL CONSTRUCTION SPECIFI <br /> Industrial % Cable.-.Tool Dia, of Well .Excavation <br /> I <br /> Domestic/private Drilled- s. Dia. of-Wel-1-Casing <br /> Domestic/public Driven ti' Gauge of Casingj <br /> Irrigation Gravel Pack zDepth of Grout SealCathodic Protection RotaryTypeDisposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PIIMP INSTALLATION: Contractor <br /> Type of Pump . . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: i <br /> .� / / State Work Done � <br /> { <br /> PESTRUCTION OF WELL: Well Diameter dt <br /> Approximate D pth D `! <br /> Describe Material and Procedure <br /> Toro cc <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 GROUT NG tANP A FINAL INSPECTION. Y <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE`SIDE) <br /> FOR DEPARTMENT.USE ONLY <br /> PHASE I � _ 1 <br /> APPLICATION ACCEPTED BY / :Z<_ •. DATE K.71 7 <br /> ADDIT.IONAL.,,COMMENTS: <br /> PHASE 'II' GROUT nINSPE ON PHA I/F NAL INSPECTI <br /> INSPECTION'BY� DATE INSPECTION BY n,.,,� DATE 1,s 7 7 <br /> 1/ 9 77 AA <br /> E H 1426 Rev. 1-74 �c.�� ��"" �' ��C 1117 - 2M' <br />