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��SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE 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 1 YEAR FROM DATE ISSUED ' Date Issued <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 _Ordiriance No. 1862 and the Rules and Regulations of the San Joaquin Local Health. District. <br /> i <br /> JOB ADDRESS/LOCATION 3 p �'. , CENSUS TRACT - <br />. <br /> Cfianer's Name �� t -� - . . Phone <br /> Address d r rt)_OyrC City <br /> Contractor's Name ;:, License # Phone <br /> L <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN- /—/ RECONDITION /_/ DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR ' je: PUMP REPLACEMENT /_7 <br /> Other U-7 -- <br /> 1 <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 I Cable Tool Dia. of Well Excavation i <br /> —�c_ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation` . Gravel Pack Depth of Grout Seal W <br /> Cathodic Protedtion I Rotary Type of Grout <br /> Disposal Other Other Information <br /> Gea h sical.> <br /> p Y Surface Seal Installed By: <br /> PUMP INSTALLATION:___, Contractor , -. <br /> I Type of Pump �YOro, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done.: .�- d <br /> DESTRUCTION 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 ae.11 and notify them before putting the -well in use. The above <br /> information is true to the best of my krqmikedge and-belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUIIJG AND A FINALIINSPECTI A <br /> SIGNED! TITLE , <br /> D �_ ONRUES E SIDE} <br /> - <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 9' 17- Z <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT INSPECTION PHASE / AL NSPECTIQN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74. 3/76. 2M <br />