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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zy- z& 1d <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 des bed, This application is made in compliance with San Joaquin <br /> County Ordinance No. 62 and the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT <br /> Owner's Name . ,. Phone <br /> Address City <br /> Contractor's Name License # Phone X/2q <br /> TYPE OF WORK (Check): NEW WELL /Z�-DEEPEN /7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / UMP REPAIR j_/ PUMP REPLACEMENT /_7 <br /> Other f_1 r — <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 s <br /> Industrial A.- E -ble Tool Dia. of Well Excavation <br /> &00-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 <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: /_7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply- h-^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 nevi,well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify=them:bef ore 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 GR2KINJAND A FI INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) T <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE (� <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTI6N BY }' DATE INSPECTION BY DATE <br /> 1, E H 1426 Rev. 1-74 1-74 2M .�` <br />