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`r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFtOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS' PERMIT EXPIRES 1 YEAR'. FROM DATE ISSUED Date Issued <br /> E _ (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 OrdinancerNo. ,1862 and" the...Rule. and Regulations of the San Joaquin Local Health ]district. <br /> JOB ADDRESS/LOCATION / CENSUS TRACT <br /> Owner's Name Phone <br /> ��'�� , <br /> Address Q^- City __ _.� ---- <br /> Contractor's Name+ �� License # G Phone `` <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION l / PUMP REP IR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: . SEPTIC .TANK SEWER LINES _ PIT. PRIVY <br /> SEWAGE1DISPOSAL 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 f Drilled Dia. of Well Casing p <br /> Domestic/public Driven Gauge of,,_Casing - <br /> gatiori""° -- Gravel Pack Depth oGrout Seal <br /> ,Ca:th.od. .e Pr-otec�ti on�...�-..-- ...;Rotary-- ._- -M-Type- -of--Grout---- <br /> Disposal f Other, t Other Information <br /> Geophysical. F Surface Seal Installed By: <br /> i 4 <br /> ! w s4 <br /> PUMP INSTALLATION: Contractor ; M /�� �``�7 <br /> Type of Pump .P. <br /> PUMP REPLACEMENT: ] 4 / / State Work Done <br /> PUMP REPAIR: / / State Work: Done <br /> DES-TRUCTION OF WELL: ` Well Diameter; ? e Approximate Depth <br /> Describe Material and Pro Jure' i <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AN . A NAI, INSPECTION. <br /> SIGNED TITLE <br /> `(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY rz-7-77 44.0 kms+ <br /> F r / <br /> PHASE I D� ��_h�J� <br /> APPLICATION ACCEPTEDBY /`% <br />'i ADDITIONAL COMMENTS: 3 <br /> k PHASE II GROUT INSPECTION PHASE-III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE y; <br /> . b/77 2M <br /> E H 1426 Rev. . 1-74 <br />