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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE; 1601 E. Hazelton Ave, , Stockton, Calif. <br /> f , Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 391J <br /> THIS PERMIT EXPIRES 1 YEAR FROM-;DATE 'ISSUED76- � <br /> Date Issued <br /> 7 -� <br /> (Complete In. Tri `�- <br /> plic�ate) <br /> Application is hereby made to the San Joaquin Local Health District for a. permit to construct <br />! and/or .instar 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 /> Jos ADDRESS/LOCATION. <br /> MISTRACT <br /> .Owner's Name Phone <br /> Address 11'49, 1 <br /> city '. <br /> Contractor's Name - <br /> License Phon27Z s � <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN /? RECONDITION.//_? DESTRUCTION <br /> PUMP INSTALLATION /G pLTMtp REPAIR /� PUMP REPLACEMENT/? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ES <br /> �� SEWER LINESY � PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE,PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF LLa c� <br /> I dustrial, :-,_., `> CONSTRUCTION SPECIFICATIONS <br /> Cable Tool �- ,Dia:---of .Weil Excavation <br /> Dam stic/private --Drilled ,Dia. of.Well Casing O <br /> _ Domestic/public Driven Gauge'of'"Casing <br /> Irrigation <br /> Graj <br /> vel Pack Depth-of Grout-Seal <br /> Cathodic Protection Rotar <br /> Die Deal Y t <br /> Type o€ Grou ; <br /> p <br /> Other ' Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: ContractorG <br /> Type- of Pump <br /> PUMP REPLACEMENT:-. / / State Work Done <br /> Pi1MP REPAIR: / / State Work Done . . . . <br /> BES;TRUCTION- OF WELL: <br /> Well. Diameter <br /> • ., Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of theanJoaquin 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 GR TIG AND A FT INSPECTION. <br /> SIGNED <br /> TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE i <br /> FOR DEPARTMENT USE ONLY <br /> � � ,. <br /> AI'ICATION' ACCEPTED BY DATE . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE 7 7� _�_ INSPECTION BY � DATE 7� <br /> E H 1426 Rev. 1-74 ._ 1.I've .,�R <br />