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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR iOFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S---4 allP <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 Disttict 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 C US TRACT <br /> Owner's Name ` <br /> Ccs Phone J ,r <br /> Address Q City <br /> Contractor's Name , " License "x, 1.37a Phone <br /> .36 LC UL <br /> TYPE OF WORK (Check) NEW WELL /�7 DEEPEN TF RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION I I PUMP REPAIR / I PUMP REPLACEMENT <br /> Other <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 DOME TIC WELL <br /> INTENDED USE j TYPE OT WELL CONSTRUCTION SPECIFICATIONS q <br /> ' <br /> Industrial `; ``_.., 1..._. .__ <br /> 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 Rotar T <br /> y ype of Grout <br /> --Disposal Other "- '_ ether 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: /7 State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 5 <br /> t <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 putCirig. the-well in-use.. The above <br /> information is true to the-best of my.knowledge and belief. ;�1 WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GiOUTM AND A <br /> FINAL INSPECTION. 1 <br /> SIGNED +TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> ' t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II MUTI PECTION PHASE III FINAL INSPECTION ! <br /> INSPECTION By DATE INSPECTION BY DATE A6 , � <br /> 19 <br /> . H 1426 Rev. 1-74 1 <br />