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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ! FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR. WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 -T�&) <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 andel Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �12 CENSUS TRACT <br /> t <br /> Owner's Name Phone <br /> i <br /> Address RA City <br /> r� r <br /> Contractor's Name Q License P}ione <br /> TYPE OF WORK (Check): NEW WELLDEEPEN / / RECONDITION DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES PIT PRIVT <br /> SEWAGE DISPOSAL FIELD/ CESS OOL/SEEPAGE--PIT < < OTHER <br /> PROPERTY LINE. - PRIVATE DOMESTIC WELtA— PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPE OF WELL `'CONSTRUCTION SPECIFICATIONS \ <br /> Industrial able Tool , Dia� of Well Excavation cQ <br /> ;�'Vomestic/private Drilled Via.' of Well, Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1: < <br /> Cathodic Protection, Rotary Type of Grout <br /> C2 70 <br /> Disposal Other Other Information 1 <br /> Geophysical Surface Seal Installed By: \ <br /> PUMP INSTALLATION: Contractor `H.P. <br /> Type of Pump _ <br /> p f 4 <br /> PUMP REPLACEMENT: / / State Work Done ! ; ,<~ <br /> PUMP REPAIR: / / State Work Done i . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> /,j <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 <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is rue to the best o my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU' I D F NAL I CTI <br /> SIGNED , TITLE <br /> ` DRAW PL LAN 'ON RE RSE SIDE I' <br /> FO DEPARTMENT USE ONLY It <br /> N <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASEJU/FINA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 .2M <br /> E H 1426 Rev. 1-74 <br />