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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—il'OFFICE USE: V--'3601 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 6 �sr <br /> } (Complete In Triplicate) - <br /> Applicati�n is hereby :Wade 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 ., CENSUS TRACT <br /> Owner's Name Phonec <br /> Address . City TGG11- ra N <br /> ` t <br /> f Contractor's Name ' License �'2 <br /> Phone ] <br /> TYPE OF-WORK (Check): NEW- WELL ' DEEPEN '/7 RECONDITION /-7DESTRUCTION /_7PUMP INSTALLATION / j PUMP REPAIR /-7—pump REPLACEMENT /7 <br /> Other <br /> 7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGi DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'' - PUBLIC DOMESTIC WELL �. <br /> INTENDED USE LTYPE OF WELL CONSTRUCTION SPECIFICATIONS 0 <br /> Industrial '' `'I Cable Tool Dia. of Well Excavation <br /> Domestic/private .4 Drilled Dia. of Well Casing '4 La lz�l <br /> Domestic/public i Driven Gauge of Casing I <br /> Irrigation 1 Gravel Pack Depth of Grout Seal (J <br /> Cathodic Protection IRotary Type of Grout ,7''-" <br /> Disposal r Other Other Information <br /> Geophysical Surface SealInstalledBy_: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> EES•TRUCTION 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 DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> k WELL DRILLERS REPORT of the well and notify them before putting the. well in use.. The above <br /> i information is true to- the-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G D A F1 jWPECTION. <br /> SIGNED y TITLE <br /> } DRAW PLOT PLAN ON REVERSE SIDE <br /> FOReDEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE f � <br /> ADDITIONAL COMMENTS: <br /> FUSE II UT INSPECTION PHASE II F AL INSPECTION <br /> INSPECTION BY -`� ATE -f; `j INSPECTION BY DATE �4 <br /> - E.H. 1426 Rev. Z-74 r 1-74 ?M <br />