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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQh OFFICE-USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued JAN 1 6 197,8 <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. 18622 /and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / f .�-.� � CENSUS TRACT <br /> : Owner's Name Phone <br /> Address /Ll City ���_ <br /> Contractor's Name d License #-;;r Phone <br /> � e <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /,,,EllESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> / /".PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 5'-PIT PRIVY <br /> SEWAGE, DISPOSAL FIELD CESSP00L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too.1 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 B : <br /> 'PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> .PUMP REPLACEMENT: State Work Done.: aUc� <br /> PUMP .REPAIR: / / State Work Done <br /> J <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to-coumply i`th-aI:r-lawsr"and-regulation`s-of--the-lSan Joaquin-Local-Health-Dist-rict <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> lafter 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -70 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS CTION PHAS I /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> E H ].1+26 Rev. _1-74., . 117.7 <br /> .moi <br />