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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOK,OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - <br /> THIS <br /> o. —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 /> Iand/or install the work herein described. This application is made in- compliance with San Joaqui <br /> . County Ordinance No. 1862 and the Rut and Mations of the San Joaquin Local Health District. <br /> 30B ADDRESS/ C ILO AT N CENSUS TRACT <br /> Owner's Name Phone , <br /> Address City 'G <br /> Contractorls Name License JO9 Phone <br /> TYPE OF WORK (Check): ��-w— <br /> .rr NEW WELL f jam`DEEPEN /� 'RECANDITION -/ DESTRUCTION f_J <br /> PUMP INSTALLATION / I PUMP REPAIR:/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C <br /> R SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL.. CONSTRUCTION SPECIFICLT12ES <br /> Industrial Cable Tool 'Dia. of Well Excavation ! 1 • C <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 -_ Surf ace Seal -Installed By _ <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. ' <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP;:REPADR-: -State^-Work Done--- - <br /> 2ES•TRUCTION OF WELL: Well Diameter 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 <br /> after completion of my work on a new well, I will furnish the San-Joaquin Local Health District e <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 /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED I -. t TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F , M <br /> FOg DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE�� 74 <br /> ADDITIONAL COMMENTS: s <br /> PHASE II GROUT ,INSPECTIOW PHASE III FINAL INS ECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t <br /> 475 E H 1426 Rev. 1-74 1 _ ?.M <br />