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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�.OFFJICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> `. <br /> Telephone:p (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 1--/. <br /> 1 (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 San Joaquin Local Health District. <br /> _ i <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License # 51,1 , Phone �jJ��'� <br /> .f k <br /> f� l <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION DESTRUCTION /_7 <br /> c <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT '/-7 <br /> Other / / I <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 L CONSTRUCTION SPECIFIC IONS <br /> Industrial able Tool Dia.. of Well Excavation <br /> Domestic/private Drilled Dia, of Well. Casing + <br /> Domestic/public Driven Gauge of Casing <br />�rigation '' , Gravel Pack Depth of Grout Seal <br /> Cathodic Protection r `Rotary Type of Grout J <br /> Disposal Other Other Information �� 3 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump " H.P. <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP .REPAIR: /7 State.Work Doney-- <br /> DESTRUCTION OF WELL:AD <br /> meter � ' <br /> Approximate Depth <br /> e ial Pro dureI hereby agree to coll laws a regulation the-San Joaquin Local Health District <br /> and the State of Caltaining to or regulat ' g wall ''construction. Within FIFTEEN DAS 1 <br /> 3fter. completion of my work on a new well, I will furnish the San Joaquin Local Health Di'strijt a <br /> 4ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformatiorj,elfF true to t est of my knowledge and belief. I WILL C KFOR A GROUT INSPECTION ' <br />'RIOATOING D A INSPECTION. <br /> SIGNTITLE(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY'HAS <br /> LPPLICATION ACCEPTED BY DATE/- �' 7 8 r <br /> LDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />_NSPECTION BY DATE INSPECTION BY DATE <br /> ti <br /> E H 1426 Rev. 1-74 IJ77 <br />