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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. Z i 46 6i'9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J Z >-14 <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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J CENSUS TRACT <br /> Owner's-Name— Phone 523+ <br /> Address rgy Cityf <br /> Contractor's NameVLicense Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP .REPAIR / / PUMP REPLACEMENT / / <br /> Other "�" -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <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 V <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done > <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure \n <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 to the best of my knowledge and belief. I WILL 9aL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A 4INAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PL T PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I y <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TIJ/JVINAL 14SPECTION <br /> INSPECTION BY DATE INSPECTION BY G✓ TE <br /> . 3/76 2M <br /> E H 1426 Rev. 1-74 <br />