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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBtOFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �75_-31 l?"!o <br /> T EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> THIS PERMIT �._ <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 Na. 1862 and the Rules and Regulations of the San Joaquin Local Health District.` <br /> JOB ADDRESS/LOCATION <br /> . CENSUS TRACT <br /> IT1 <br /> Owner's Name Phone <br /> Address 3 JYT City1d'i-� <br /> Contractor's Name -License honeFl�L� <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN j RECONDITION"/?.-DESTRUCTION /7 I.. <br /> PUMP INSTALLATION PUMP REPAIR REPLACEMENT /? V\ <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,e 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 We11�Casing4 <br /> Domestic/public Driven_, Gauge of._Casing - -- - <br /> Irrigation _'--'.„_ "Gravel Pack Depth of Grout Seal � <br /> a <br /> Cathodic-Protection Rotary Type of Grout <br /> 13isposal ,:. ;� A Other Other Information <br /> Geophysical Surface Seal Installed BX: I <br /> PUMP INSTALLATION: ContractorTM <br /> Typeof Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �* <br /> f PUMP '.REPAIR: /_7 State Work Done p <br /> PES`IRUCTION OF WELL: Well Diameter i J 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 of the well and notify1them before putting the- well in.use.. The above <br /> information is true to the-best-of- my knowledge._.a_nd belief. I WILL CAL FOR A GROUT INSPECTION <br /> ' PRIOR TO UTING AND FINAL INSPECTION, f <br /> SIGNED TITLE j&LL - <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> }- FOR DEPARTMENT USE ONLY <br /> P r. PHASE I <br /> APPLICATION'ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> 111 PHASE Ii GROUT IHO#ECTION PHASE III FINAL INSPECT4QN <br /> .4INSPECTION BY DATE <br /> INSPECTION BY DATE +� <br /> ' 1-74 2M <br /> `t E H 1426 Rev. 1-74 .ti. � � - <br />