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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—,OFFICE USE: 1601 E. Hazelton.Ave. , .Stockton, Calif. <br /> ! Telephone: (209) '466-6781 <br /> APPLICATION FOR- WELL CONSTRUCTION OR PUMP PERMIT Permit No. �/O <br /> i <br /> THIS PERMIT EXPIRES l 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 F <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 /> 1Y,JOB ADDRESS/LOCATION �.7"c��� C) � 6r*f:,4gA - o p CENSUS TRACT <br /> Owner's Name /� Phone - <br /> Address --- <br /> `J CC/ �- --x�~ City <br /> g <br /> Contractor's Named License # Phone <br /> ,. TYPE OF WORK (Check): NEW WELL '/ DEEPEN '/ RECONDITION /-7 DESTRUCTION -17 <br /> PUMP INSTALLATION PUMP REPAIR /-7 PUMP REPLACEMENT. /-7 <br /> Other40 <br /> /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIKE <br /> S PIT PRIVY <br /> SEWAGE DI_SPOS FIELD . CESSPOOL/SEEPAGE PIT OTHER pp <br /> PROPERTY LINE -- PRIVATE MESTIC WELL PUBLIC 5WTIC WELL "V <br /> IN <br /> INTENDED USE TYPE OF WELL CONSTRUCTSPECIFICATIONS , <br /> - - ON � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven. Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> s Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ] / State Work Done <br /> PUMP REPAIR; __/?-.-State Work Done, <br /> ,RES®RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lawns 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 GRO NG AND X.FINALANSPE ON. <br /> SIGNED TITLE <br /> DRA LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 10'f�%,!G INSPECTION BY DATE <br /> ti ,*,E H 1426 Rev. 1-74 1-74�11� <br />