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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO1,iQFFICE USE: 1601 E. Hazelton Ave,. .Stockton, Calif. <br /> Telephone: ­(20;) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No l.C) <br /> 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 Distract for a permit to construct <br /> t and/or install the work herein described. This application. is made in compliance with San Joaquin <br /> County Ordinance No. 18x622 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" �f <br /> ft City <br /> Contractorts .Name I ,� License " hone f <br /> f <br /> TYPE OF WORK (Check): INEWWELL #DEEPEN ' RECONDITION /_7 DESTRUCTION (7 <br /> :PUMP INSTAL /7 TION PUMP REPAIR /_/ PUMP REPLACEMENT /7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC T 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 s� ^I <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> .Cathodic Protection Rotary Type of Grout <br /> Disposal Otherme <br /> Other Information <br /> Geophysical � Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor : - � - f • <br /> Type of Pump H.P. <br /> PUMP, REPLACEMENT: / State Work Done <br /> PUMP 'REPAIR: '1/7State Work Done <br /> &ES.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> �- Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of therSan; 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 al <br /> WELL DRILLERSiREPORT ; the well and notify them before putting. the..well in.use.. The above <br /> :information 'is t tothe y kno ledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTI FINAL I SPE Q_ <br /> SIGNED TITLE <br /> (DRAW PLOT PLO ON REVERSE SIDE - <br /> 'FOR DEPARTMENT USE ONLY <br /> PHASE I * " <br /> APPLICATION ACCEPTED BY' � <br /> DATE �^� 761 <br /> ADDITIONAL_ COMMENT'S: �. � <br /> PHASE II GROUT INSPECTION PHASE. III FINAL INSPECTION <br /> INSPECTION BY 11' DATE INSPECTION BY DATE <br /> ' ,E H 1426 Rev. -L-74� <br /> �. M 1-74 2M <br />