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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 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 <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 workiherein 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 (�Q CENSUS TRACT <br /> Owner's Name ? <br /> Phone <br /> Address 2 Acliz57 <br /> City f r T <br /> i <br /> Contractor's Name License /�L ! <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /L- - PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 2,J 54 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia. of Well Excavation <br /> J,--gomest ic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing J t <br /> Irrigation Gravel PaIf Ick Depth of Grout Seal f <br /> ,Cathodic Protectionataxy Type of Grout <br /> "Iiispos'al Other Other Information . <br /> Geophysical Y hIf _ { <br /> Surface Seal Installed By: <br /> PUMR:.INSTALLATION-: - -,Contractor <br /> t <br /> i .. <Type' of Primp .P. <br /> PUMP REPLACEMENT: .,,. <br /> /.�./jFftate Work Done <br /> PUMP .REPAIR: ' /' / State Work Done <br /> D.ESTRiJGTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I he.eby agree to comply:,with all laws and regulations of the San Joaquin Local Health District <br /> and -the State of'Gali.fornia pertaining to or regulating well 'constructi.on. Within FIFTEEN DAYS <br /> after completionof 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 GRO IN D A FINAL INSPECT . . :. <br /> SIGNED - TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I a �� <br /> APPLICATION ACCEPTED BY %a DATE <br /> ADDITIONAL COMMENTS: <br /> ' PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - A2 DATE -7. <br /> E H 1426 Rev. • 1-74 ii �' �i��. � . 0/77 . 2M <br />