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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. Z:LD ��D <br /> THIS PERMIT EXPIRES I 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 Rule an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION/76 CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name �z License Phone <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> 0 ther /' / <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation N <br /> Domestic/private Drilled Dia. of Well Casing �V <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 Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor_, . _ <br /> ._�, . <br /> A .. w.._ ,. Type of Pump (n�,. .H.P. 1, <br /> PUMP REPLACEMENT: State Work Done !�-� - -tYc-0 <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 e best of my knowledge and belief. I WILL qALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING An'/A /FINAL INSP1jCTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1�✓ DATE ` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO P /FINA INSPECTION <br /> INSPECTION BY DATE Z44 INSPECTION B DATE S—S'--7 7 <br /> 7.7 <br /> E H 1426 Rev. 1-74 <br />