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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ���/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .��a <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 Regulationsofthe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION > 0 1_0 a0 L10fes— ' CENSUS TRACT <br /> Owner's Name Phone <br /> Address ® City <br /> Contractor's Name , License old Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / 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 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seals <br /> Cathodic Protection Rotary Type of Grout p <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> � . <br /> PUMP INSTALLATION: Contractor <br /> __Type- of. -PumpH.P.. - <br /> PUMP REPLACEMENT: State Work Done <br /> r 3 <br /> PUMP REPAIR: / / State Work .Done s . <br /> DESTRUCTION 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 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 OR A GROUT INSPECTION <br /> PRIOR TO G OUTING FI AL IN CTION. <br /> SIGNED TITLE <br /> DRAW PL T PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II UT INSPECTION PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2-V-76 _ <br /> .. 3/76 2M <br /> E H 1426 Rev. 1-74 <br />