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fit r , SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> 70—E"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> VTelephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUrT PERMIT permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made ti 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 /> �r d ii <br /> JOB ADDRESS/LOCATION CoL CENSUS TRACT <br /> / l <br /> Owner's Name Phone <br /> Address S / City <br /> Contractor's Name `� 4i License License iL�12Q4/)Phone( E� <br /> p , <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN %/ RECONDITION / / DESTRUCTION /_ <br /> r PUMP INSTALLATION '/—/ PUMP REPAIR '/ / PUMP REPLACEMENT f, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <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 <br /> Domestic/private Drilled Dia. of Well Casing \� <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed B .: <br /> 'PUMP INSTALLATION:._ -contractor <br />' Type of Pump H.P. <br /> - �i, PUMP REPLACEMENT: '/ / State Work Done a �•� <br /> PUMP .REPAIR: (StateWorlc 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 the best of my knowledge and belief. I WILL CAL FOR A GROUT INSPECTI N <br /> PRIOR TO G TING F;NAL INSPECTION. <br /> s SIGNED TITLE <br /> DRAW PL T PLAN 'ON REVERSE SID-E), <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �a2 <br /> ADDITIONAL COMMENTS: 1 <br /> f PHASE II GROUTIINSPECTION PHASE :I /FINAL INSPECTION <br /> I INSPECTION BY :DATE INSPECTION BY W ATE <br /> E H-1426 Rev. 1-74 <br /> ' 3/76 2m <br />