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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <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 Issued <br /> .4p[,--C//_ . (Complete In Triplicate) 223 - L�fC�-12. <br /> plicatidn-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 ` 4 CENSUS TRACT <br /> Owner's Name Phone i <br /> Address � City / <br /> Contractor's Name %� 4 License # Phone : / <br /> i <br /> TYPE OF WORK (Check) : NEW WELL -/_7 DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLAT ON PUMP REPAIR/ / • PUMP LACE NT IT <br /> Other <br /> E7 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <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 of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information.. I <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION. Contractor <br /> T}" a of Pump <br /> PUMP REPLACEMENT: / / State Work Done ; <br /> -_ m <br /> PUMP .REPAIR: / / State Work Done <br /> I — <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 the .well in use. The above <br /> information is true the best of my knowledge and belief. I WILL CJcbL FOR A GROUT INSPECTION <br /> PRIOR TO UTING D A FINAL INSPECTION. <br /> SIGNED TITLE , <br /> DRAW PWT PLAN ON RE FRSE SIDE , <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> INSPECTION BY TE INSPECTION BY <br /> 3/76 214 <br /> E H 1426 Rev. 1-74 <br />