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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT�;OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z - Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '.f.,T-7� <br />!` Application is hereby made to the San(Joaquin eLocalrHealth District fora permit to construct <br /> and/or install the work herein described. ' This application is made-in compliance with SanJoa'quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI N .� CENSUS TRACT <br /> 4 <br /> Owner's Name Phone.] <br /> Address City <br /> If <br /> Contractor's Name <br /> License �la�3Phone3 <br /> TYPE OF WORKCheck): NEW WELL /�:� <br /> ( DEEPEN /_7 RECONDITION /? DESTRUCTION /- <br /> PUMP INSTALLATION/ / PUMP REPAIR - PUMP REPLACEMENT -7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL q <br /> INTENDED USE -TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> ' Industrial `Cable Tool Dia. of Well Excavation <br /> Domestic/private i Mrilled Dia, of Well Casing <br /> Domestic/public Driven , Gauge of Casing <br /> Irrigatign - Gravel Peck Depth of Grouts Seal ti <br /> Cathodic ProtectionRotary a Type of Grout <br /> Disposal 'Other ; E Other Information , �( <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump <br /> c: H.P. / Q <br /> PUMP REPLACEMENT. <br /> a L/ State iWork Done <br /> PUMP_'REPAIR; "' :State aWork Donee <br /> . r ! <br /> I <br /> DESTRUCTION:OF_WELL'::. "We11.Diameter-..- - -1:-Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply -with all laws and regulations of the San .3oaquin Local Health District i <br /> And the State of California pertaining to or regulating well 'consiruction. 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 aiid notify them before putting- the-well- in-use... The above <br /> information true to the' est.of- my.-knowledge and belief. I WILL,.CALL FORA GROUT INSPECTION <br />.PRIOR TO GROfINGAND AL INSPE ION. Y i <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 COMMENTS: _ --- <br /> PHASE II GROUT ,INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY . DATE -.INSPECTION BYDATE <br /> 9 H 1426 Rev. 1-74 _ r 1./7K 9M <br />