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SAN JOAQUIN LOCAL HEALTH DISTRICT _- <br /> ToE`-7OFFICE USE: 1602 E. Hazelton Ave-. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S��cL <br /> THIS PERMIT EXPIRES I 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 <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 R <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name t License # Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/? RECONDITION /7 DESTRUCTION f7 <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 <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 Tyke of Grout <br /> Disposal Other Other Information <br /> Geophysical -- Surface Seal Installed By.* . <br /> PUMP INSTALLATION: Contractor , <br /> TypE of 'ump H.P. <br /> PUMP REPLACEMENT: r State Work Done0 4—Ah I <br /> i <br /> PUMP .REPAIR: /7 State, Work.. Done <br /> ES•TRUCTION OF WELL: Well Diatiieter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulationstof the San Joaquin Local. Health District � <br /> and the State of C `lifornia p taming to or regulat.tng well. construction. Within FIFTEEN DAYS <br /> after completion o my work on`a new well,- I will ;furnish the San Joaquin Local Health District a <br /> WELL DRILLERSof t well and notify them bef utting..the. well in-use.. The above <br /> informationis17RT <br /> a to th es of. my knowledge #belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTANDA FI SPECTION. <br /> SIGNED AZL TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> ED op"11— <br /> FOR DEPARTMENT ,USE ONLY I <br /> `PHASE I <br /> APPLICATION ACCEPTED BY DATE TJ <br /> ADDITIONAL COMMENTS: <br /> PHASE OUT XNSPECTION PHASE TI11F_TNAL INSPECTION <br /> INSPECTION By DATE INSPECTION' BY DATE I <br /> E H 142 I <br /> 6 Rev. 1-74 _ . 1_7,. qxx - <br />