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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> : OR OFFI USE: 1601 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 I8s`ued1 <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 Regulations of the San Joaquin Local Health District. <br /> ��1 <br /> JOB ADDRESS/LOCATION !� d Q.i,r�r � CENSUS TRACT <br /> Owner's Name ,C <br /> - S' V Phone �n <br /> ' Address /dr e City CJ <br /> Contractor's Name License <br /> Phone <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN. / / RECONDITION /-7 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 /> PROPERY 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 Q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed:___ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. `7 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure. <br /> r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District I <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. m .. wledge an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUZING AND A FINAL; I <br /> SIGNED - r-7 J TLE <br /> 3L P AN 'ON RSE SIDE `1` <br /> PHASE I <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I — — <br /> PHASE .II G AUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 4VDATE INSPECTION BY �l,'� DATE <br /> � I <br /> E.H 1426 Rev, 1-74 - ' 3/76 2M <br />