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SAN J'OAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFF`SCE USE: 1601 E. Hazelton Ave. , .Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - g,g <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is tereby 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 Diptrict. <br /> JOB ADDRESS/LOCATION CENSUS TRACT. <br /> Owner's Name . r Phone _ -- <br /> Address <br /> city J <br /> Contractor's Name License Phone r <br /> TYPE OF WORRCheck i <br /> ( ) NEW WELL /% DEEPEN/% RECONDITION 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 ; <br /> Industrial Cable Tool Dia. of Well Excavation I <br /> !-r Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type• of Grout <br /> Disposal Other Other Information <br /> Geophysical ' ` <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> or f <br /> PUMP .REPAIR: A <br /> State Work Done- f i <br /> DESTRUCTION 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 to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO GROUTINC AND A FINAL NSPECTIO <br /> SIGNED - TITLE <br /> DRAW PLO PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> -7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE Ix/ INSPECTION <br /> INSPECTION BY DATE Al Z INSPECTION BY DATE 9—.44-2 <br /> E H 1426 Rev. 1-74 W IJ77 " om <br />