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- - - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 I YEAR FROM DATE ISSUED Date Issued Z d,.? <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 CENSUS TRACT <br /> z , <br /> Owner's Name Phone J <br /> Y <br /> Address '2S_> City <br /> Contractor's Name Li e �� �u <br /> c nse f�J P <br /> hone 4 3 <br /> TYPE OF WORK (Cheek) : NEW WELL/ DEEPEN/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT 17 <br /> 0ther <br /> DISTANCE TO NEAREST: SEPTIC TANK 75 Q 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 -Tool Dia. of Well ,Excavation <br /> mastic/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 Type of Grout �- <br /> Disposal . _ Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> .00 <br /> PUMP REPLACEMENT: / / State Work Done <br /> . - <br /> oPUMP-`.REPATR:--- --j_77State.W-rk"Done , <br /> . -.:. <br /> P_ES�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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-beat of- my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO UTING ANDA ZINAL INSPEffAON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDET�� ,...._„ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: " <br /> PHASE II GROUT INSPECTION PHASE IZ FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -/ <br /> E <br />' i µE H 1426 Rev. 1-74 1_7� ' <br />