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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 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 1 YEAR FROM DATE ISSUED Date Issued -71 <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 and Re lations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone ' <br /> Address <br /> City <br /> Contractor's Name License #-1 Phone / <br /> i <br /> TYPE OF WORK ((heck) : NEW WELL / / DE %% RECONDITION /7 DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATIO PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / rs . <br /> DISTANCE TO N SEPTIC TANK R LINES PIT PRIVY <br /> SEWAGE DISPOSAL F C SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - P E D S C WELL PUBLIC DOMESTIC WELL <br /> INTENDED S TYPE OF WE L CONSTRUCTION SPECIFICATIONS �. <br /> Industri Cable o ia. of Well Excavation <br /> Domestic Lrillic <br /> ate Drill Dia. of Well Casing <br /> Domestic Drive Gauge of Casing <br /> Irrigati Grave k Depth of Grout Seal <br /> Cathodic tection - Rotar Type .of Grout <br /> Disposal Other Other Information <br /> al B <br /> TQN <br /> Type of Pump H.P. <br /> PUMP REPLACEMEFT. / / State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WE L: 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 f alifornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completi n f my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS P RT of the well and notify them before putting the -well in use. The above <br /> information is tr a to the-best of my knowledge and belief. I WILL CALIA FOR A GROUT INSPECTION <br /> PRIOR TO OUT NG IN INSPE ON. <br /> SIGNED TITLE <br /> DRAW P T PLAN ON RE FRSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYZr DATE q-�/>.`•]-� <br /> E H 1426 Rev. 1-74 376 2M <br />