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f 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, �Ja <br /> THIS PERMIT EXPIRES l YEAR FROM DATE' ISSUED Date Issued �6 <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 R ions of the San Raquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone "-(07 <br /> Address ` City Get -cam <br /> Contractor's Name 6Z License �� ,� Phone <br /> • i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <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 \n. <br /> Industrial Cable Tool Dia. of Well Excavation �] <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public <br /> Driven E Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Otherv.. Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor?'!;/ <br /> Type of Pump H.P. <br /> _ t ' <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP -REPAIR: / / State Work Done <br /> DES.TRU.CTION-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 we11 '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 true t e best of my.-knowledge and belief. I WILL CAJ_,VF4R A GROUT INSPECTION <br /> PRIOR TOG UTING AND INS N. <br /> SIGNED TITL {� <br /> (DRAW :POT PLAN 'ON REVERSE SIDE7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f DATE <br /> APPLICATION ACCEPTED BY (N <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IJJOINAL_INSPECTION } <br /> INSPECTION BY DATE INSPECTION BY ATE f-/ 6 <br /> E H 1426 Rev. -l-74 3/76 2M <br />