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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />{ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 3 6 1 <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/LOCAT,ION CENSUS TRACT <br /> iOwner's Name Phone )eS74— <br /> Address/ City , - <br /> - -- --- - - <br /> Contractor's Name License #,�WPhone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN _/ RECONDITION /_/ DESTRUCTION /_ <br /> AL <br /> G PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other �/ / <br /> f <br /> DISTANCE TO NEAREST: SEPTIC "TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C� <br /> PROPERTY LINE -' PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <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 /> Type of Pump H.P. <br /> %�7 <br /> PUMP REPLACEMENT: � State Work Donee•"-.C.� <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> iI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land 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 INSPECTION <br /> (PRIOR TO GROUTI G AND A FINAL INSPECTION <br /> k SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> ,PHASE I <br /> APPLICATION ACCEPTED BY DATE 6/— �7-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTTW, P`j1ASA%III/FIFAL INSPECTION <br /> INSPECTION BY RATE N INSPECTION BY DATE <br /> i/7] 2M <br /> E H 1426 Rev. 1-74 <br />