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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�g/� 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z,2 J <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 ,Ioaqui <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 �� Phone <br /> �� � <br /> Address City <br /> Contractor's Name r F License &A-5Phone.fl -f 9 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_—/ DESTRUCTION /_7 - <br /> PUMP INSTALLATION f PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYLINE - 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 y Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation "i 'Gravel Pa-ck Depth of Grout Seal <br /> Cathodic Protection, 'Rotary -_ Type "df Grout <br />—Disposal-- Other -Other Information <br /> Geophysical Surface Seal Installed B . <br /> PUMP INSTALLATION: Contractor 40 <br /> Type of Pump - - + H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> — i <br /> PUMR .REPAIR: ._ . . / /,State Wo.rk_Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <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 's true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />°RIOR TO GRO TINGAU A F,4NAL XNSPECTION. { <br /> SIGNED TITLE <br /> I (DRAW PLOT PIAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z-- <br /> ---E .IB 1426 R2-9- 1-74 _ <br />