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1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r©Q j V CENSUS TRACT ' <br /> Owner's Name r Phone �- <br /> Address ,__ S.l 'Y�7 city , <br /> Contractor's Name MJ�f —� License # 1 fa Phone <br /> TYPE OF WORK Check) NEW WELL / / : DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT G <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1� <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 /> —Ind usrfi7n-l­-- —C-a-6 ool— `R—D`Ia: of'We1j' Excavation <br /> Domestic/private Drilled Did; of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel`'Pacli Depth of Grout-Seal <br /> Cathodic Protection 4 Rotary Type of Grout. <br /> Disposal l Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:• ' <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:- / State Work Done <br /> PUMP .REPAIR: - / / ,State 4 o-'.rk Done <br /> 1 <br /> DES-TRUCTION OF WELL: Well Diameter <br />-- 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 f <br /> after completion of my work on .a new well, I will furnish the San Joaquin Focal"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 li <br />?RIOR TO GROU G AND FI L INSPECTION: <br /> SIGNED TITLE ' <br /> _ p <br /> (DRAW PLOT PLAN ON REVERSE SIM) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ��'` <br /> APPLICATION ACCEPTED BY <br /> DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINA INSPECTION <br /> INSPECTION BY DATE n// INSPECTION B W DATE 'S 2r <br /> E H 1426 Rev. - I-74 y"`�` 6/77 _ 2M <br />