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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f 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 <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 herein4described. This application is made in compliance with San Joequin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT ` <br /> ..I I <br /> s <br /> Owner's Name Phone <br /> i <br /> Address City 7 <br /> 6 <br /> Contractor's Name 94License 11-2 �a Phone <br /> _ i <br /> TYPE OF WORK (Check NEW WELL/ / DEEPEN / J RECONDITION / / DESTRUCTION/_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ,� <br /> Other / t/ °Q } <br /> 1 � E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (�1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT, PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> /,--Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of .Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal A Other Other Information <br /> Geophysical Surface Seal Installed By: <br />'UMP INSTALLATION: {{ - <br /> Contractor <br /> Type of Pump <br /> H.P. <br />'UMP REPLACEMENT: State Work Done <br /> F <br /> UMP .REPAIR: State Work Done` <br /> ES-TRUCTION OF WELL: Well Diameter <br /> Describe'Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of-.the Sats. Joaquin Local Health District <br /> nd the State of California pertaining to or regulating-well 'construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the -well in use.. The-above <br /> nformation is true to the best of my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ZIOR TO GRO&ING -AND A FINAL, INSP C ON. <br /> IGNED �_,1J <br /> ` !il <br /> DRAW TITLE �PL T PLAN ON REVERSE SIDE) t <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br />?PLICATION ACCEPTED BY DATE ' <br />)DITIONAL COMMENTS: i 1 <br /> PHASE II GROUT INSPECTION PHAS I I/FINAL INSPECTIO <br /> JSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1177 <br />