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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: CJ"" 1601 E. Hazelton 'Ave. Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z2-Sg'6zd <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 described. This application is made in compliance with San Joaquin , <br /> County Ordinance No. 1862 and the Rules an Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> e <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License ���� Phone �,6 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <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 SPECIFI ONS <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 <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT /-7 State Work Done <br /> PUMP .REPAIR: / / 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 the w n use. The above <br /> information is true po the best of my knowledge and belief. I WILL L F R A GROUT PECTIO <br /> PRIOR TO GROUTING fi3k A FINAL INSPE —N.— <br /> SIGNED <br /> .SIGNED TITLE <br /> DRAW FLOT PLAN -ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE -� �7z <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />