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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave . ; Stockton, Calif. r <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 f <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 /> JOB AliC�S/LOCATION (f r r "V CENSUS TRACT <br /> ..�. <br /> Owner's Name �y Phone <br /> Address City <br /> Contractor's Name S License � �Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /VPUMP REPAIR / / PUMP REPLACEMENT / / c j <br /> Other <br /> DISTANCE TO NEAREST-:, SEPTIC TANK ,/- SEWER LINES IT 'PRIVY �' a <br /> SEWAGE DISPOS;, PRIVATE <br /> ELD �� CESSPOOL/SEEPAGE PIT (ETHER D <br /> PROPERTY LINE` DOMESTIC WELL`A Ct PUBLIC DOMESTIC WELL, <br /> INTENDED USE TYPE OF WELL' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 4-- Dia, of Well Excavation <br /> f JF <br /> Tke`�!rpomestic/private Drilled Dia: ofi Well Casing <br /> Domestic/public Driven Gauge of Casing ; <br /> Irrigation. Gravel .Pack 'Depth of Grout Seal 1� r� � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information F <br /> Geophysical 'Surface Seal Installed By: _ - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P� <br /> PUMP REPLACEMENT: FT State Work Done„^..._. .. . f .. <br /> M� <br /> PUMP .REPAIR: / / State Work Done kA I <br /> STRUCTION OF WELL Well Diameter; y j Approximate Dept j <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 true to the best of my knowle <br /> .,Age n belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> ( LO L ON REVERSE SIDE) <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE �r <br /> ADDITIONAL COMMENTS: <br /> P E I OUT INSPECTIONP ' S I/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -' <br /> 0/77 _ 2M <br /> E H 1426 Rev. , 1-74 Q <br />