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F <br /> 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <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 Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address r <br /> �� J City . <br /> Contractor's Name ': /U,�.� ! License 4� Ph ne <br /> �_ � <br /> TYPE OF WORK`(Cher:k)c NEW WELL /V""DEEPEN, /_/ RECONDITION / // DESTRUCTION J-T <br /> PUMP INSTALLATION / J PUMP REPAIR/ / PUMP�REPLACEMENT J—T` <br /> .. Other / / , r` / p� <br /> 4DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IT PRIVY <br /> SEWAGE._DISPO IELD4 � CESSPO /SEEPAGE PIT OTHER <br /> -PROPERTY LINE -- PRIVATE._-DOMES.TIC_WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE +TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial abler ool'` Dia..4 .of.Well Excavation /' <br /> �✓Irmestic/privateer Drilled ` Dia. of Well Casing '� <br /> Domestic 7j �. .,. --r,._ .._ _ — <br /> /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 /> Geophysical Surface Seal Installed BX.`: 'z" '11% <br /> PUMP INSTALLATION: Contractor "� I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work bone + "' <br /> PUMP .REPAIR: / / State Work Done <br /> tPES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia-1 and Procedure <br />. I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land the State of California pertaining to or regulating well 'coristruction. 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 C,4LL FOR A GROUT INSPECTION <br />!PRIOR TO GR O NG AN A F Lilli$PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />'APPLICATION ACCEPTED BY DATEf� <br /> ADDITIONAL COMMENTS: <br /> ._..-- -'- -PRASE�l-I-GROUT I-NSPECT30N.----- A . -- -. PHASE III/FINAL 'INSPECTION <br /> INSPECTION„-BY,a,-----. ---- YDATE,- -- - _ INSPECTION BY_ , ,�V. DATE -z_1- <br /> 6 ., E H 1426 Rev. 1-74 1177 2M <br />