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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued !I-1L—1,5— <br /> (Complete In Triplicate) ' <br /> Appliedtion 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 Regulations of the San Joaquin Local Health District. <br /> / AT ` CENSUS TRACT <br /> JOB ADDRESS/LOCA I N r 77u.�.p .,,.,. <br /> Owner's Name Phone 3 <br /> Address �... .2 1 2, / L City <br /> - �. <br /> Contractor's_Name ��} - - �. License ��/fc Z373 Phone ; <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 r6 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled, Dia-. of Well Casing \ <br /> Domestic/public, —Driven - _ -k 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 ,CJ - <br /> Type 6f'Pump H.P. <br /> PUMP REPLACEMENT: f State Work Done <br /> ,PUMP i.REPAIR: L/ State Work Done - <br /> ,RES�RUCTIO_N_ O_F 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 /> f 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 CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTOG 4ED A FINM4 INSPECTION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> f R DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE l L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 'f .E <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />