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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: lll/// 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466 -678 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Or <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 <br /> and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /�� 9 7 / CENSUS TRACT <br /> Owner's Name Phone <br /> Address '- 6 4922 City _ <br /> Contractor's Name , _ License ��'�S�s Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_ 1 <br /> PUMA INSTALLATION / / PUMP REPAIR b-q PUMP REPLACEMENT /_7 °Q <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 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 `l1 <br /> Geophysical. t Surface Seal Installed By: T <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 /> .De ribe Material and Pro e ure U <br /> I hereby agree to comply with all laws and r-,,- 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 DistriE a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 AROUTING AND VFINdL INSPECTION. <br /> SIGNED TITLE _O�� i <br /> (DRAW PLOT PLAN -ON REVERSE SIDE) U / <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYZ;%& DATE <br /> ADDITIONAL COMMENTS: <br /> P I GROUT INSPECTION P*SdL&MFINAL INSPE TION p <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - 1-74 " <br /> 6��77 _ 2M <br />