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SAN JOAQUIN LOCAL HEALTH- DISTRICT.. . <br /> 'Ok OFFIC9'USF,: 1601 E. Hazelton Ave. , Stockton, Calif-. 7J <br /> Telephone: (209) 466 -6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z/- <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 Regulat' ns of the San Joaquin Local Health District.' <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address 4".anCity �- <br /> Contractor's Name '� License �� � ?Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/vf/"DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATIO ' / PUMP REPAIR / / PUMP REPLACEMENT -7 i <br /> Other <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 /> 1 � <br /> IqLdustrial Cable Tool Dia. of Well Excavation / �v <br /> _ t omestic/private Drilled Dia, of Well Casing i\ <br /> Domestic/public Driven Gauge of Casing f <br /> Irrigation Gravel Pack Depth of Grout Seal ®' <br /> Cathodic Protections °--otary Type of Grout <br /> Disposal Other Other Information + <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT % State Work Done <br /> PUMP .REPAIR: / / State Work Done N�I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r ,,,',Describe Material and Procedure <br /> 1 ' <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_t in use. The ove <br /> information is true to the-best of my owledge and belief. 1 ILL CALL FOR A GR PECTION <br /> PRIOR TO GROUTING DSA FINAL INSPE <br /> SIGNED TLE <br /> DRAW PL T' PLAN ON RE LRSE 5 <br /> FOR DEPARTMENT USE ON <br /> PHASE I _ w...,,.... <br /> APPLICATION ACCEPTED BY DATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 1 PHASE III/F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />