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J/ SAN J0AQUIN LOCAL HEALTH DISTRICT <br /> FOFi,•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 l YEAR FROM DATE ISSUED Date Issued -la r <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 appXication is made in compliance with San Joaquin' <br /> County- Ordinance No. 1862 an the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name?)k. Phone <br /> Address <br /> ity . <br /> Contractor s Name :License $hon <br /> po <br /> s yY err', - �• <br /> TYPE OF WORK '(Check): NEW -WELL /? DPEN'�j� REf)ONDITiON' f EST -%f �v. 4 <br /> PUMP INSTALLATION / PUMP REPAIR ,/—/ PUMP REPLACEMENT /-7 <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 WELS,' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL_ J CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too3. " Dia. of Well Excavation <br /> Domestic/private Drilled _ Dia.--of Well Geeing- s <br /> - 1 <br /> Domestic/public Driven -\ Gauge of Casing i <br /> Irrigation Gravel Pack. Depth •off Grout Seal` <br /> Cathodic Protection Rotary Type of Grout s <br /> Disposal. Other other Information <br /> Geophysical SurAace Seal Installed BY: <br />-PUMP INSTALLATION: Contractor ,. t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: .' / / State Work Done <br /> PUMP .REPAIR: / / State Work. Done <br /> DE5•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 of the well and notify them before putting.. the..well. in.use... .The above <br /> information is true to •the•best .of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED " TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE . <br /> ADDITIONAL CONMENTS:- <br /> PHASE II GROUT INSPECTION PHA9 jUaINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 3426 Rev. 1-74n !x/75 2M <br />