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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S- <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r4 (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 Re lations of the San Joaquin Local Health District. <br /> 'JOB ADDRESS/LOCATION i <br /> CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> e i <br /> Address City ; _ <br /> Contractor Name �'/� License phone � j <br /> r ' 1 <br /> TYPE OF WORK (Check): NEW WELL17 T DEEPEN /? RECONDITION /-7 DESTRUCTION'f7 <br /> PUMP INSTALLATION / / PUMP REPAIR I PUMP REPLAC <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> 5 SEWAGEJ: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 V <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation r.l Gravel Pack Depth of Grout Seal 1 <br /> t Cathodic Protection 1 Rotary Type of Grout <br /> F 7 Other Other Information <br /> } Disposal <br /> Geophysical ! Surface 5e�ayAyirnstal]ed B <br /> PUMP INSTALLATION: Contractor PUMPf ±,4 <br /> TypePof Pump H,P. <br /> PUMP REPLACEMENT: � State Work Done <br /> I - 1 <br /> PUMP `.REPAIR: /_7 State Work Done <br /> I ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> i 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 CfiA FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINALSP CTION. <br /> SIGNED0 <br /> TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY _ DATE w INSPECTION BY DATE .. - S' <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 ' _ <br />