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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _FOR OFFICEUSE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209): 466-6781 <br /> e APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> y (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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />,. JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name E T Phone <br /> - 6 <br /> Address <br /> City <br /> Contractor's Name - License ��Z grj <br /> � t Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN .%,/`. RECONDITION /_7 DESTRUCTION /7 <br /> PUMP: INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> .Other'//.�. __ <br /> DISTANCE T04NF-AREST: SEPTIC ,TANK 1Q� SEWER LINES�� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> � � CESSPOOL/SEEPAGE PIT. OTHER � <br /> PROPERTY LINE - PRIVATE DOMESTIC,WELL PUBLIC DOMESTIC WELL <br /> INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industfial '' =` ! <br /> i Cable Toole Dia, of Well Excavation /01 <br /> Domestic/private i;7,%Drilled; : ,� rDia. of Well Casing i� <br /> Domestic/public f ;Driven—`� Gauge of Casing Z <br /> Irrigation , Gravel Pack.• , Depth of Grout Seal pi v <br /> Cathodic Protection Rotary f. Type of Grout <br /> Disposal Oth `' <br /> Other !TE <br /> "' Other Information <br /> Geophysical ' Surface= Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` f� <br /> if <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / ? State-.-Work Done <br /> kle T /,t/- <br /> PUMP <br /> i(/PUMP .REPAIR: NEw <br /> State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter " 1`t1', <br /> Describe Material nd Procedure Approximate Depth <br /> a <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District r <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAIS <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 GRO NG AN" A AL INSP TION. <br /> SIGNED <br /> TITLE ! --- <br /> _ _(DRAW PLOT P.LAN.=ON...REVERSE -SIDE). i� <br /> ` <br /> PHASE I FOR DEPARTMENT USE ONLY ! <br /> � <br /> APPLICATION ACCEPTED BY I <br /> ADDITIONAL COMMENTS: / -` Z DATE <br /> PHASE II GROUT NSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /0 T <br /> r <br /> E H 1426 Rev. 1-74 <br />