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Y �. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ._ - T--- <br /> i FOfirOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. { <br /> Telephone: (209) -.466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Ted <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ' <br /> (Complete In Triplicate) ��ry / <br /> 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 .ma.de in compliance with .San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distri.c't. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> �- <br /> Phone -- /� ► <br /> `1. � . <br /> Address ?lit <br /> City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN ,/ RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ -7 REPAIR /� PUMP REPLACEMENT <br /> Other Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />-� SEWAGE DISPOSAL FIELD !Q+1 CESSPOOL/SEEPAGE PIT - OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL:'— PUBLIC DOMESTIC WELL f <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Indust al Cable .Tool Dia. of Well Ex avati_on �( <br /> Domes c/private -- r Dri ed `- Dia:`of`Well sing <br /> Dome tic/public Dr en Gauge of Cas g <br /> Irr gation G vel Pack Depth of Gr ut Seal <br /> C hodic Protection Lary Type of G ut <br /> sposal ther Other In ormation $ <br /> eophysical 'Surface Seal Installed 8 ~ <br /> PUMP INSTAL TION: Contractor <br /> Type of Pu H.P. <br /> _ r <br /> PUNP REP CEMENT: / IT Sta a Work Done <br /> PUMP '.REPAIR: t7 State Work Done <br /> f} <br /> ES;TRUCTION OF WELL: Well Diameter �� ; y Approximate Depth <br /> Describe Material and Procedure --�---- <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 j <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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION.__ _ <br /> SIGNED TITLE' <br /> DRAW PLOT PLAN_ ON REVERSE SIDE <br /> PHASE I <br /> FO DEPARTMENT USE ONLY J <br /> I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE IINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �- <br /> ti ^E H 1426 Rev. 1-74 �,q4 e-1Z 14&.G <br /> _ 1-74 2Ni. ' <br />