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SAN JOAQUIN LOCAL HEALTH DISTRICT - - - <br /> FOR MFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-5781, <br /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP PEIRMIT Permit No. <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. 1852Mnjo the s and•Regula ns of the an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `J`� � � <br /> i x ON cENsus TRACT <br /> Owner's Name51 f� <br /> Pl�one <br /> Address Cit <br /> Contractor's Name License a� �Phoneme O �7— <br /> TYPE OF WORK (Check):T NEW WELL /? DEEPEN /? RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION /% PUMP REPAIR /. _PUMP REPLACEMENT <br /> Other /_7 <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 p , Drilled Dia. ,of Well-.Casing <br /> Domestic/public_ Driven Gauge of Casing <br /> Irrigation Q Gravel Pack Depth of Grout Seal � M <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical. Surface Seal Installed BY: r <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P. <br />:PUMP REPLACEMENT: State Work Don <br /> F <br /> PW :REPAIR: - w State'Work Done�"r' ,"."`�.,, <br /> ,RESmRUCTION OF,WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with Fall 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 ray work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the will and notify them before` putting. 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 f <br /> PRIOR TO GROUTING AND A .FINAL INSPECTION. r <br /> SIGNED i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I w -7 <br /> APPLICATION ACCEPTED BY ! DATE /C/ z / ��j <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION° BY DATE INSPECTION BY DATE <br />`t E H 1426 Rev. 1-74 1-74 <br />