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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. } <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7'f <br /> I! THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i, (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 /> �I <br /> JOB ADDRESS/LOCATION 2 / . O / CENSUS TRACT ' <br /> Owner's Name if c�u C� Phone <br /> s G,� City <br /> Address r9 <br /> Contractor's Name License # Phone . .: .. . <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_7 RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well, Excavation <br /> Domestic/private Drilled Dia. of' Well.-Casing <br /> Domestic/public- ;i Driven <br /> Irrigation Gravel Pacts Depth of Grout Seal w <br /> Cathodic Protection Rotary Type of Grout 71.. <br /> Disposali! Other F Other Information;. <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type`:. of Pump H.P. <br /> PUMP REPLACEMENT: • /_/ j State Work- Done _ <br /> PUMP .REPAIR: /° / State Work Done <br /> DESTRUCTION `OF WELL: Well Diameter Approximate.Depth, U <br /> Describe Material and, Procedure AOOi <br /> I .hereby agree to comp with all 1 s and,,re ations o the San Joaquin Local health DiaCrf.ct <br /> and the State of California pertaining to or regulating well'-construction. Within FIFTEEN <br /> after completion of my work on a new well,-I•-will- furnish the San Joaquin Local Health District e <br /> WELL DRILLERS REPORT ofIj.the well_. and notify them_bef_ ore putting the -well in use. The above <br /> information is true to the best o£ my..knowledge and belief. I WILL CALL FOR A GROUT INSPLCTi( <br /> PRIOR TO GR TNG AND 4 FINAL INSPECTION. <br /> SIGNED ' TITLE r <br /> ;4D W.: PLAN ON "kSE SIDE <br /> j, FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BYI DATE <br /> ADDITIONAL WMMINTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO `I <br /> INSPECTION BY i!, DATE INSPECTION BY ATE <br /> Ii r <br /> 3V96 <br /> E 9 1426 Rev. 1-74 _ h.-� n <br />