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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (249) 466-6781 u <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6_38 lo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applic4tion is hereby made to the San Joaquin Local Health Diattict 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 Regulations of the San Joaquin Local Health District. <br /> Ii A/ <br /> JOB-ADDRESS/LOCATION f'�IW CENSUS TRACT <br /> Owner's Name Phone i <br /> Address City PWgtg� 9a La <br /> Contractor's Name j �� azo_i License # Phoned 3 <br /> TYPE OF WORK (Check): NEW WELL DEEP /7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /• / PUMP REPAIR /% PUMP REPLACEMENT J <br /> Other /J <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 B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `.REPAIR: /_7 State Work Done <br /> 2ES;TRUCTION WELL:OF WWell 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 an 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 SALFOR A GROUT INSPECTION <br /> PRIOR TO GRFINAL FINAL INSP ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRQUA INSPECTION PHASE I NAL NSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE Z <br />( � R H 1426 Rev. 1-74 1-74 2M <br />