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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�:,:�I7 <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. Th`s application is made in compliance with San Joaquin <br /> County Ordinance No. 18 and the Ru ando gulation � the San Joaquin Local Health District. <br /> 9,,je CENSUS TRACT <br /> JOB ADDRESS/LOCA <br /> i.. <br /> Owner's Name, Phone q3114 <br /> ���i " <br /> Address Ciptf <br /> Contractor's Name License/ <br /> Jho�S ��f-- <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /- <br /> Other 1-7 w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER .LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER _ 1 <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL: PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL :CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of ,Well`Casing <br /> Domestic/public Driven- Gauge of Casing _ Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of'-Grout <br /> _ Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> �j <br /> PUMP REPLACEMENT / / State Work Done N, <br /> PUMP .REPAIR: State Work Done <br /> Approximate DES-TRUCTION OF WELL; Well Diameter � A PP 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 GR UTING AND A FINAL INSPECTION. , <br /> SIGNED TITLE <br /> D W.-PLOT'I' PLAN ON REVERSE SIDE) I' <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IMPECTION rjjAQE _I;I/yINAL INSPECTION <br /> E INSPECTION BY DATE INSPECTION BY �--- DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />