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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. <br /> Z 44 <br /> i <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 and e lations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �U CENSUS TRACT <br /> Owner's Name Phone7 72 ^ <br /> Address Cit <br /> Contractor's Name ,ficense # <br /> -2(964F&hone <br /> - 71 I 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 SPECIFICATIONS <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ,la <br /> -b <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> I <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 well in use. The above <br /> information is tru to the best of my knowledge. and belief. I WILL CALL/VCR A GROUT INSPECTION <br /> PRIOR TO G UTING D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW Pl T PLAN `ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE fI6' <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE II /FINAL INSPECTION / <br /> INSPECTION BY DATE INSPECTION BY & DATE <br /> E H 1426 Rev. 1-74 376 2M <br />