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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />/rFOR OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. <br /> Telephone: (269) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:,-77=�jtLS'� <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 ,� 4 CENSUS TRACT <br /> i <br /> Owner's Name � - Phon"�„��. <br /> Address City �} <br /> Contractor's Name �r License �� Phone <br /> ' 7 ` ' <br /> z <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION /_/ DESTRUCTION /7 <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 DOFIESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � . <br /> Industrial Cable- Tool. E - Dia.` of :Well Excavation V <br /> Domestic/private ° Drilled °" -.bi-a_of Wel--l�Cas=ing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth­of Grout Seal <br /> Cathodic Protection Rotary Type_o'f Grout <br /> Disposal Other diSer 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 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 Satz 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 G TING ANE AFI AL I <br /> SIGNED TITL <br /> RAW PLOT PLAN ON REVERSE SI E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: XAt IM/ <br /> PHASE II--( qk�4 S CTION P S I/FI I PECTI <br /> INSPECTION BY ATE INSPECTION BY DATE / G ZI 3 <br /> - 2M <br /> L. 1426 Rev. 1-74 , <br />