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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO!�:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> E 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. 1.862 and1the Rules and Regulations of <br /> the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �o S(� C�o i CENSUS TRACT <br /> Owner's Name ��/ ��'Y' �o Phone <br /> Address oI City <br /> Contractor's Name '\{'�/rXr.a`� License Phone , <br /> TYPE OF WORK (Check): NEW WELL.-/-7 DEEPEN '/-7 RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT <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 o <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial + Cable Tool. Dia. of Well Excavation <br /> Doinestic/private I Drilled Dia. of Well Casing <br /> Domestic/public i 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 /> 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 /> l/ <br /> DES-TRUCTION OF WELL: Well, Diameter Approximate Depth <br /> Describe Material and Procedure +e%n. <br /> t <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 GROUTTXG AND A I INSPECTION. <br /> i SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t� DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO C. P E III F INSPECT <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ro; <br /> 2M <br /> R H IL76 Aati_ 7-74 <br /> 75 <br />