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_ o � SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6751 y� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 ~/3-7 <br /> (Complete In Triplicate) <br /> Application is hereby trade 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. e, CENSUS TRACT <br /> Owner Is Name r. Phone ► <br /> Address 40- 0, City f <br /> a <br /> Contractor's Name License # ejA2& hone <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN -/7 RECONDITION /? DESTRUCTION f_7 <br /> PUMP INSTALLATION / PUMP REPAIR /� PUMP REPLACEMENT /? <br /> Other ET <br /> C <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 SL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation rf <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> „ C Irrigation " Gravel, Pack Depth- of Grout Seal <br /> t ICathodic Protection " Rotary; Type of Grout r^t <br /> i Disposal ' Other = Other Information <br /> Geophysical ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ' <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT: / / . State Work Done <br /> PIMP — /_7 ' State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> p <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 /> C 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. owl�eand-,belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL INSPECT ON. <br /> SIGNED <br /> ITLE <br /> rD W P T ?I ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED( Y r <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II INSPECTION PRASE III FINAL INSPECTIO <br /> r INSPECTION BY `DATE INSPECTION BY DATE / <br /> ' E H 1426 Rev. 1-74 <br />