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4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICK USE* 1601 E. Hazelton Ave. , Stockton, Calif. <br /> • Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a- Se 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION ENSUS TRACT <br /> Owner's Name ,. I Phone - <br /> /9Z, <br /> Address %;L2City <br /> Contractor's Name .License # P?�? Phone <br /> TYPE OF WORK (Check): NEW WELL Ly DEEPEN '17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD L 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 _ 5 X it <br /> Domestic/public, Driven Gauge of Casing <br /> Irrigation ,. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection j Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BV: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done �.. ...� - 36 - 7 <br /> PUMP :REPAIR: --1? State Work Done <br /> R <br /> ES•TRUCTION 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-beat of- my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO OUTING AND INAL IN G'T _ <br /> SIGNED TITLE <br /> DRAW LOT P ON REVERSE SIDE <br /> / OR DEP T USE ONLY <br /> PHASE I i y/ <br /> ,-APPLICATION ACCEPTED ATE �f <br /> 'ADDITIONAL COMMENTS: <br /> ;. PHASE II GROUT INSPECTIONINSPECTION <br /> INSPECTION BY DATE INSPECT P I N DATE <br />€ ) E H 1426 r, Rev. 1-74 _ 1 .74 214 <br /> �-� <br />