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II SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: ,k 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> .II APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> II , (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 madein 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 qr' CENSUS TRACT <br /> Owner's Name �p � �� Phone <br /> Address h e City lflyio- 1 <br /> Contractor's Name <br /> ��.. License #� Phone e <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION / / DESTRUCTION /7 <br /> it PUMP INSTALLATION / / PUMP REPAIR /Z;1-7-PUMP REPLACEMENT //7 <br /> it other <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z <br /> r <br /> 4 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ! PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,-.- CONSTRUCTION SPECIFICATIONS 'r <br /> Industrial Cable Tool Dia, of Well Excavation pp�� <br /> Domestic/private Drilled Dia. of Well Casing Wil ' <br /> Domestic/public Driven a Gauge of Casing n <br /> eL_ Irrigation ,i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical I Surface Seal Installed By: <br /> PUMP INSTALLATION: Ir Contractor <br /> Type of Pump • . H.P, . i <br /> I � <br /> PUMP REPLACEMENT: State Work Done <br /> F <br /> PUMP .REPAIR: If /�/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> iE Describe Material and Procedure <br /> II <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the well in use.... The above <br /> information is true: <br /> 11to the best of. aiy knowledge and belief. I WILL CA4 FOR A GROUT INSPECTION <br /> PRIOR TO GROUT G AND A FINAL INSPECTION. <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> " FOR DEPARTMENT USE ONLY <br /> PHASE I Ip <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHA /F AL INSPECTI y <br /> INSPECTION BY ii DATE i INSPECTION BY DATE p <br /> it <br /> E H 1426 Rev- 3--71, 2M <br />