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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE 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 1-YEAR FROM DATE ISSUED Date Issued JAN 1B 1918 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` Z & CENSUS TRACT <br /> Owner's Name Phone 3 - <br /> Address 5 City '. <br /> Contractor's Name icense Phone <br /> TYPE OF WORK (Check) : NEW WELL /_ DEEPEN -/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 Q <br /> Industrial Cable Tool Dia. of Well Excavation 4 <br /> Domestic/private Drilled Dia. of Well Casing E/ <br /> Domestic/public Driven Gauge of_Cas_ing_ <br /> Irrigation Gravel Pack '`� 'Depth of Grout Seal J� J <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor /�-�/�c ;. � S � ' <br /> Type of Pump H.F. le2 <br /> _- <br /> PUMP REPLACEMENT: / / State Work Done" <br /> PUMP .REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 true to the best of m w-led"g'e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO CTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT .PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY "r DATE r �✓ �� 3 <br /> ADDITIONAL COMMENTS: d <br /> PHASE II GROUT INSPECTION ePSE /FININSPECTION <br /> INSPECTION BY DATE , INSPECTION B ATE <br /> E H 1426 Rpu- . 1-7L ;/77� o,r <br />