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r r <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOS* 'OFFICE E: 1601. E. Hazelton Ave. Stockton Calif. k / <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 i <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 ZAx CENSUS TRACT '. <br /> Owner's Name Phone { <br /> Address City I <br /> I <br /> Gontractor's3NAme ; \ ` �� License 4h:-.& Phone <br /> t <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ 'RECONDITION',./-/—DESTRUCTION /7 �1 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT---/-7 1 <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 /> CATI NS <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFI <br /> =mestic/private <br /> strial Cable�Tool Dia of Well' Excavation <br /> Drilled „ Dia. of 'Well Casing <br /> Domestic/public Driven .Gauge,of Casing) <br /> Irrigation G avel Pack Depth of Grout Seal c <br /> Cathodic Protection I! Rotary Type of Grout <br /> %Disposal Other Other Information <br /> Geophysical ----Surface-Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I H.P. <br /> PUMP REPLACEMENT: . /, / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> v <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 well'construction. Within FIFTEEN.-DAYS <br /> after completion of my work on-al new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofithe we+il and notify them before puttingt e n use. T bove <br /> informationis ue to the best y knowledge and belief. I WILL CALL OR A G I SPECTION <br /> PRIOR TO GR G •AND A FINAL CT ON, <br /> SIGNED TITLE <br /> PLAN ON REVERSE SIT) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .� :• _ _-. Y <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: t s <br /> PHASE II GROUT INSPECTION } P SE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 � <br /> 376 2M <br /> E' H 1.426 Rev. 1-74 " � � <br />