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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` fosiOFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone- -- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�1n1� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (`7k, <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 Nn.' 1862 and the Rules and ulatinns`of they n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. i �� " / <br /> CENSUS TRACT <br /> Owner's Name. - � " Phone � � � <br /> Address f� � ,�c�-� city. <br /> Contractor's Name License #.2A Phone Odi <br /> i` <br /> s <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEl3 /-7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION /,V—PUMP REPAIR /7 .PUMP REPLACEMENT /_7 <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 WELL <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS, <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven = Gauge of Casing V� <br />` Irrigation Gravel Pack Depth of ,Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal" a Other Other Information <br /> Geophysical. Surface Seal Installed B k <br /> PUMP INSTALLATION: Contractor01 <br /> Type of Pump 0H.P. <br /> PUMP REPLACEMENT: / / State Work Done,., L <br /> PUMP '..REPAIR: /� State 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 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 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 true to the best of my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING p A FINAL INSPECTION. <br /> SIGNED ,17 <br /> TITLE <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR EPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY DATE > 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TTI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 't ~E H 1426 Rev. 1-74 ,;1-74 2M <br />