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SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOROFFICE 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 /-2L6 <br /> (Complete In, Triplicate) <br /> ' Application 1a hereby made Ea 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 /> k County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District'. <br /> .FOB ADDRESS/LOCATION 56 � � CENSUS TRACT <br /> Owner's. Name:. Phone <br /> Address .r 6City . ,.,.... <br /> Contractor's Name License # Phone .75 <br /> E TYPE OF WORK (Check) NEW WELL /77DEEPEN '/ RECONDITION DESTRUCTION f_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7-PUMP REPLACEMENT /7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS } <br /> Industrial Cable Tool Dia. of Well Excavation U <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/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 B <br /> PUMP INSTALLATION: Contractor , <br /> '- xype of Pump k H.P. <br /> PUMP REPLACEMENT: . %/ State Work Done ' n <br /> PUMP .REPAIR; State Work Done $w <br /> IDES-TRUCTION OF WELL: Well Diameter <br /> •�-�.� --- ..., Approximate .Depth <br /> Describe Material and Procedure <br /> fl 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 /> 3PRIOR TO GROUTING .AND A FINAL INSPECTION. <br /> k .SIGNED , 7 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , i �- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I., E*H 1426 Rev,.-'1-74 . . :. .� h/75 :2NLf <br />