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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO�lOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�S= Old <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /,?--�79f <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sat: 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 /> Owner's Name hone <br /> Address /age <br /> i/ City <br /> Contractor's Name A ��,.� �Gy C_ LicensePhane „g <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_7 RECONDITION ,moi( DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/PUMP PLACEMENT 17 <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 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 /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: .L7 State Work Done _ <br /> ES•TRUCTION 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 a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT he well and notify them before putting. the..well in use. The above <br /> information is tr to the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU �lD,,.A�FINAI.;'"IN ECTICZ <br /> SIGNED TITLE <br /> 4 of DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .- ,� DATE/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FIN M PECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE 7�` <br /> ~E H 1426 Rev. 1-74 1-74 2M <br />