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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '• FOR{OF ICE USE: 1601 E. Hazelton Aver., Stockton, Calif. <br /> Telephone: '(209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /-' _57//�o/# <br /> THIS PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED Date Issued�O- <br /> (Complete In Triplicate) ,..�, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein described. This application is made in compliance with San Joaquin ` <br /> County Ordinance No. 1862 and. the Mules and., Regulations :of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name' Phone <br /> Address - p - City <br /> Contractor's Name c) a, License # one ? <br /> I <br /> - <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN17 7 RECONDITION /-7 DESTRUCTION f7 <br /> ! PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I 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 I CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. '1of Well Excavation <br /> ,�4-Domestic/private Drilled Dia. ',of Well Casing <br /> Domestic/public Driven ' Gauge of Casing `0 <br /> r Irrigation Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection Rotary Typekof' Grout <br /> Disposal Other Other Information <br /> Geophysical. ... 5urf.a';'ce Seal Installed $ <br /> PUMP INSTALLATION: ` irw t <br /> Contractor .�..�_ <br /> Type of Pump N H.P. rC— <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: State Work Done " .1 <br /> i <br /> 4ESTRUCTION_ 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 /> I 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 knowled nmd-b lief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO G&OUTING AND A FINAL IN PE I N. <br /> SIGNED 1 149 1 Q ,r --- <br /> YV. (DLAW OT PLAN—ON REVERSE SIDE) <br /> I. - R DEPARTMENT VSE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY -7�C1lr DATE � 't <br /> ADDITIONAL COMMENTS: <br /> { PHASE II GROUT INSPECTION PHAS III/FINAL-INSPECTION . <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> t E H 1426 Rev. 1-74 1-74 2M <br />