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SANE JOAQUIN LOCAL HEALTH DISTRICT <br />` FOR+OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephgne: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION.-OR PUMP PERMIT Permit No. » � <br />`. <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 •Distriet 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. a� M UNl�►eD �`� ���r'°� CENSUS TRACT <br /> Owner'a Name •C L:Q�. Phone��9 3az� <br /> Address i" - City L d <br /> Contractor a Name <br /> License � -Phone ` <br /> TYPE OF WORK (Check};_ NEW WELL/ T DEEPEN '/7 RECONDITION %j DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLAC <br /> 6-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK V SEWER' LINES PIT PRIVY Q <br /> SEWAGE 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 <br /> Domestic/public Driven Gauge-°o€ Casing <br /> IrrigationGravel Pack Depth of Grout Seal ' <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal Other Other Information <br /> ; 3 Geophysical Surface Seal Installed B <br />' PUMP INSTALLATION: Contractor <br /> g Type of Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP ,.REPAIR: /7 State Work Done <br /> ES�TRUCTION OF WELL: Well Diameter- �� Approximate Depth 4��,, <br /> 1 "" Describe Material And Procedure fidr, S <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 /> i 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. TO GRO ING AND A PI AL IN PECTION. , <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> - ,.FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> k <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION PHASE III FINAL INSPECTION <br /> G INSPECTION BY DATE INSPECTION `BY DATE <br /> 1-74 2M_ <br /> __ZH 1426 Rev. 1-74 -; - <br />