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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF�:OFFICE T3SE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. af <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> ,Application is hereby made to the San Joaquin Local health District for a permit to construct i <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 /> JOB ADDRESS/LOCATION P; �• <br /> CENSUS TRACT <br /> Owner Ia Name <br /> Phone ' <br /> Address C1 �. <br /> City , !r� <br /> Contractor's Name C: A <br /> License .2 Phone <br /> TYPE OF WORK (Check): NEW WELL /_7­DtEPEN RECONDITION 1`7' DESTRUCTION /77 <br /> PUMP INSTALLATI0N ./_7 PUMP REPAIR -7 PUMP REPLACEMENT jL7 <br /> Other <br /> Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD Z � PIT PRIVY _ <br /> PROPERTY LINE - PRIVATE DOMESTIC CESSPOOL/SEEPAGE �" OTHER t� <br /> INTENDED .USE TYPE OF WELL LIC HMESTIC WELL <br />_ Industrial CONSTRUCTION SPECIFICATION <br /> � Cable Tool Dia. or-Weil Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public- Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> _Disposal Other Other Information <br /> Geophysical . <br /> A - Surface Seal Installed .B : f <br /> PUMP INSTALLATION Contractor F <br /> Type of!Pump <br /> A.P. ' <br /> PUMP REPLACEMENT; State Work Done <br /> PUMP .REPAIR: /7 'State Work Done <br />)ES,TRUCTION OF WELL: Well 'Diameter <br /> Describe Material and Procedure Approximate Depth <br /> C hereby agree to comply with a1aws and regulations of the San Joaquin Local Health District <br /> Ind the State of California pertaining to or regulating;well "construction. Within FIFTEEN DAYS <br /> tfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and •notify-them-before putting the-well in-use... .The above <br /> nformation is true to the-best-of- my knowledge and belief. WILL CALL FORA GROUT INSPECTION <br /> IGNED GROUTING -FIN SPECTION. <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br />'BASE I FOR DEPARTMENT USE -ONLY E <br /> TPLICATION ACCEPTED BY Q <br /> DDIT.IONL COMMENTS: DATE , `� "- <br /> PHASE II-GROUT-INSPECTION - PHASE III FINAL PECTION <br /> NSPECTION SY ^ DATE INSPECTION-BY <br /> . _ DATE <br /> E H 1426 Rev. .1-74 J <br />