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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR'OFFICE U E: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THISPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 11 (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 /> d <br /> 'JOB ADDRESS/LOCATION / CENSUS TRACT ' <br /> Owner's Name Phone <br /> p .f <br /> Address Q '- City <br /> Contractor's Nameaj� � License ����� 'J Phone <br /> ti .. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION_/ / DESTRUCTION /_7flQ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_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 DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A Cable Tool . Dia, of Well Excavation <br /> Domestic/private # •, Drilled., —,Dia. of Well Casing � <br /> Domestic/public A Driven Gauge of Casing <br /> Irrigation I Gravel-Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal Other- Other Information <br /> Geophysical r, ► Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractof <br /> Type of Pump ". I H.P. <br /> _ � . <br /> .PUMP REPLACEMENT: / 7 tate Work Done <br /> PUMP -REPAIR: / f State Work Done <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 DA�S <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 ;cell 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 ajZOUTING A FINkL INSPECTION. <br /> F SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i. PHASE I �- ! 7�`7 i�," <br /> APPLICATION ACCEPTED. BY W DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION � PHASE FIN NSPECT ON <br /> INSPECTION BY DATE / r INSPECTION BY ATE -711 <br /> E H 1426 Rev. 1-74 _ <br />