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SAN JOAQUIN LOCAL: HEALTH DISTRICT <br /> FWTU FICE USE: 1601 E. Ha elton 'Ave., Stockton, Calif. <br /> Telhone: (209) 466-6781 <br /> APPLICATION FOt WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,..4,) <br /> THIS PERMIT EXPIRES I 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 /> i 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/LOCAT.1ON CENSUS TRACT <br /> Owner r s Name Phone <br /> Address D vz City ���i_ <br /> { Contractor's Name R; License MkZZYPhone <br /> NEW WELL - DEEPEN/� RECONDITION /-7 DESTRUCTION <br /> ' TYPE OF WORK {Check): _ - <br /> PUMP INSTALLATION / I PUMP. REPAIR /-7—PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT i OTHER <br /> � . PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i': Cable Tool Dia. of Well Excavation6 <br /> s Domestic/private, , Drilled Dia. of Well Casin <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal d <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: / / State Work Done - <br /> k Q <br /> PUMP,..REPAIR: ` f¢ <br /> /7 State Work Done <br /> � 9 <br /> 2 S-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 /> WELL DRILLERS REPO T'of. the well and notify them before putting the..well:. in:use. The above <br /> information i ue to the•best of- my,knor'aledge and -belief. I WILL CALLr'FOR"A GROUT INSPECTION <br /> PRIOR TO G AND-A-FI ECT ON. ` <br /> SIGNED •. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE G <br /> ADDITIONAL COMMENTS: /07/-?" .. - 32 IY- <br /> PHASE II ogkOUT INSPEC IO PHA I/ INAL INSPECTIO <br /> INSPECTION BY r• DATE - INSPECTION BY DATE Z 2-7 <br /> J R E H 1426 Rev. 1-74 1-74 2M <br />