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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 79-06 <br /> f tom. !/ <br /> l THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued d <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> oil <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> _ <br /> Owner's Name Phone <br /> 4 � <br /> Address City <br /> + Contractor's{Name iAlLicense # Phone <br /> 6 k <br /> a <br /> of - <br /> TYPE OF WORK (Check•):: NEW WELLDEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> k h PUMP INS AL ATION / / PUMP REPAIR /. / PUMP REPLACEMENT /- <br /> i Other <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWE LINES PIV PRIVY s`'1 <br /> SEWAGE-DISPOS�IELD - /_ CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE "1'1 RTVA OMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPF, OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cab1e Tool-----Dia. of Well Excavation � <br /> Domestic/private Drilled {Dia`: of Well Casing /� A <br /> Domestic/public ! 1V1 .. Driveenn, f Gauge of Casingzzz <br /> Irrigation Pack 'Depth of Grout Seal <br /> Cathodic Protection Rotary• Type ,.of Grout zz <br /> Disposal Other:., Other Informat on r <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 /> 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 FOR A GROUT INSPECTILV <br /> 'PRIOR TO GRO ING D A F NA I SPE�TION. <br /> SIGNEDTITLE <br /> RAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIONACCEPTED BY _ DATE, u' <br /> ADDITIONAL COMMENTS: - - - <br /> -`" —-PHASE-11- -PHASE I . �TIN-AL-INSPECTION- <br /> ' INSPECTION BY DATE INSPECTION BY DATE JJ--;?k <br /> lJ77 <br /> E H 1426 Rev. 1-74 L• =t <br />