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SAN JOAQUIN LOCAL HEALTH DISTRICT J <br /> F0F'90FFICR USE: 1601 E. Hazelton Ave. , Stockton, Calif. 4 t <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 IssuedDEC 7? <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/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone d?</p <br /> Address ,A-1 4 ,-� r� City e ' <br /> Contractor's Name five :1.4A-C License � 7 PhoneIV <br /> t <br /> L 0 <br /> �1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /? _ <br /> PUMP INSTALL..ATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> _. Other <br /> DISTANCE TO NEAREST: SEPTIC TANK la r SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD /G?1I CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN jPRIVATE 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 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 /> .� <br /> Type of Pump r ; H.P. <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUMP ''REPAIR: / / State Work 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 thewell 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE�� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: !' <br /> PHASE II 0 NSPECTION PHASEWI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> E H 1426 6/77 9M <br />