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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FORWELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> V TI <br /> THIS ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, - <br /> % . <br /> ssued, . <br /> (Complete In Triplicate) <br /> Application is hereby made to.Ithe 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. . la�ndtthe Rules and Regulations of the ,San Joaquin Local Health District. <br /> It'If 657 4a c <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone r <br /> Address .. . . ,. ZQ C2 City h'G /W"�. . <br /> Contractor's Name i �..� License Phone <br /> a <br /> TYPE OF WORK (Check) NEW WELL / / --DEEPEN / / 'RECONDITION ./ / DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other /_7 _o1 <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 I 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 DepEi of Grout Seal <br /> Cathodic Protection-, J-`,i Rotary�.�, 4 Type of Grout, <br /> Disposal 1 Other Other Information ®� <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:State Work •Donery <br /> `;y. y <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 Sart 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 GROU NG AND A FI L T PECTION. j <br /> SIGNED TITLE f <br /> (DRAW PLOT PLAN ON REVERSE SIDK)/ <br /> FOR DEPARTMENT USE ONLY., j <br /> PHASE I <br /> APPLICATION ACCEPTED BY Cel_- DATE1d�7 <br /> ADDITIONAL COMMENTS: Al <br /> PHASE II G OUT INSPECTION -- -- PHAS "'FININSPECTIONINSPECTION BY DATE 1, / INSPECTION BYDATE <br /> E H 1426 Rev. 11-74 - <br />