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S LJOAQUIN LOCAL HEALTH.DISTRICT <br /> .FOE OFFICE USE: �/ 160: . Hazelton Ave. , Stockton, Cale <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' Ordinance No. 1862 and the Rules and Re ulations of the an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � ( � 9 CENSUS TRA.6T <br /> Owner's Name ' t •�G�iyl� Phone r/ � y <br /> Address City <br /> Contractor's Named License ���/Phone <br /> TYPE OF WORK (Check) : NEW. WELL/ DEEPEN / / . RECONDITION /? DESTRUCTION /? <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT . r T <br /> Other <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 Cable Tool Dia: of Well Excavation <br /> =Domestic/private Drilled Dia. of Well Casing <br /> Domestic'/public Driven Gauge of Casing f - <br /> Irrigation Gravel Pack Dep:�h of Grout Seal <br /> Cathodic Protection /.—,Rotary Type of Grout fit, <br /> Disposal' Other Other Informati6h ' [y <br /> Geophysical Surface Seal installed B .: <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> } PUMP .REPAIR: / / State `Work Dome 4 <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 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 GROUTING AND A FI Na I PE ION. <br /> SIGNED C, TITLE <br /> D W P T T' PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATf � <br /> ADDITIONAL COMMENTS <br /> PHASE II' GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DACE . t� ' INSPECTION BY DATE p j""7 C..: <br /> rt 3/76 2M <br /> E H 1426 Rev. ':1-74 ' <br />