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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. a-Zg4 7 <br /> t <br /> THIS 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 ofyNthe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address f /� City <br /> Contractor s Name � � .1�- <br /> ` License Phone �� <br /> 3 � <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPE / / RECONDITION / / DESTRUCTION /—T <br /> r PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other 1-P <br /> DISTANCE TO NEAREST: SEPTICITANK t. ,.. SEWER LINES PIT PRIVY <br /> i SEWAGE4DISPOSAL FIELD CESSPOOL/SEEPAGE RIT 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 <br /> Domestic/public ! Driven _ Gauge of Casing �1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection f Rotary. Type of Grout <br /> Disposal ! Other ` " Other Information <br /> Geophysical Sur.f.ace.. Seal_Ins..talled...B_ : <br /> PUMP INSTALLATION: Contractor <br /> Type 'of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> k PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter L 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 /> a 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 CK2 FOR A GROUT INSPECTION <br /> ` PRIOR TO GROUTIN D A FINAL INSPECTION. <br /> ! SIGNED TITLE <br /> „ DRAW PL T PLAN 'ON REVERSE SIDE) i; <br /> 4 R DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASF, 11 GROUT INSPECTION PHASE 41 FIN4 INSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> K .S,c/ dies' G,.X47 le 4o .sZ <br /> `, E H 1426 Rev. 1-74 �1�p .G✓ vse5 a��P��l�e- �.�/A 7y� i 7 3/76 2M <br />