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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 FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -fig kJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7 <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 ��� _ � CENSUS TRACT ' <br /> Owner's Name Phone <br /> AddressQh� r - - -- City _ <br /> Contractor's Name XJ License #/6.2173 Phone. (:.?-r-?,?C <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN D4 RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other J-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 O <br /> Industrial _ 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_ Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information C� <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: 17 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 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 thewell in use. The above <br /> Information.4 true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GRJOU.TING INAL INSPEGTION. <br /> SIGNED TITLE <br /> W PLAN 'ON WERRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE ire/ /��'/� <br /> ADDITIONAL COMMRNTS: 0 0 <br /> PHASE II GROUT INSPECTION PHASE II14EINAL INSPEC 10N - <br /> INSPECTION BY DATE INSPECTION BY f DATE 2 �� <br /> x/76 a <br /> E H 1426 Bev. 1-74 <br />