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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR-,WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7_ 41,7,74 <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. 1852 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION d Zj1-1 CENSUS TRACT <br /> Owner's Name `. .. : ` Ph on67. <br /> ' �1' . <br /> Address 1 � � ,./¢�/ Ci.tq ' -" / <br /> Contractor's Nato <br /> � _?�0 _-. License >�}Phone <br /> TYPE OF WORK 4ChecNEW WELL Ly DEEPEN /_- RECONDITION l— DESTRUCTION Imo" <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE M 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 <br /> _Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done71t <br /> PUMP-,.REEPAIR., /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 Californiarpertaining 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-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE / <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I Ni4i. INSPECTION <br /> INSPECTION BY iDATE INSPECTION B DATE <br /> t . <br /> t E H 1426 Rev. 1-74 1-74 2M <br />