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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � <br /> r - <br /> F.FOfl+OFFICEJUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,;;,- <br /> THIS <br /> 7THIS 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 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 P & CENSUS TRACT <br /> Owner°s Name fj " <br /> I G,Phone 5771 .,.. <br /> Address City ' <br /> Contractor's Name - License Phone 4/ZZ J 3 ];r <br /> TYPE OF WORK (Check): NEW WELLDEEPEN '/__7 RECONDITION /7 DESTRUCTION ] J <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT 17 <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F �� <br /> Industrial Cable Too! Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation Gravel Pack Depth-of Grout` Seal <br /> Cathodic Protection _ Rotary Type of Grout' �G&ZAl/ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f_1 State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ES•TRUCTION 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-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT D A FINAL AINSPECTION. <br /> SIGNED 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 gjOUT INSPECTION PHASE III INAL INSPECT ON <br /> INSPECTION BY DATEZ7 INSPECTION BYDATE <br />`1 µE H 1426 Rev. 1-74 '"`7=14 2M <br />