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z1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USt r' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued =. <br /> 11 (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 /> lations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules and Regu <br /> JOB ADDRESS/LOCATION 16 Al CENSUS TRACT <br /> k ` Phone <br /> Owner's Name <br /> - �/ <br /> City <br /> Address <br /> Contractor's Name <br /> j License �a Phone ~' � •f`' <br /> TYPE OF WORK (Check) : NEW WELL/ I DEEPEN V I RECONDITION_/ / DESTRUCTION /7 <br /> PUMP INSTALLATION%f 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 <br /> MESTICATIONS \ <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION S <br /> Industrial Cable Tool Dia. df Well Excavation <br /> Domestic/private <br /> Drilled Dia..,;of- Well Casing <br /> � <br /> Domestic/public Driven Gauge 'of Casing <br /> Irrigation Gravel---Pack Depth .of Grout Seal <br /> f Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Surface Seal Installed <br /> Geophysical B <br /> 1 PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> PUMP REPLACEMENT: State Work Done,.. ,,.. ,� <br /> / <br /> PUMP .REPAIR: / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter_, <br /> Describe Material and Procedure ` <br /> 3;. <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 /> r, after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting th.e' 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 A FINAL INSPE 0 TITLE1P 1001 ,:51 <br /> SIGNED <br /> • D W PL T' PLAN 'ON RE FRSE SIDE <br /> F ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY i <br /> ADDITIONAL COMMENTS: IHASE I I/FINAL INSPECTION <br /> PHASE I GROUT INSPECTION INSPECTION BY DATE/-Z f=7 <br /> INSPECTION BY 1 DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />