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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR' OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) <br /> Application is hereby made toythe 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 Q; - CENSUS TRACT <br /> Owner's Name Phone —» <br /> 15 Address4 City , <br /> s <br /> Contractor's Name f � License # �gAdo Phone <br /> l <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITIONS/ / DESTRUCTION /_7' PUMP INAL <br /> STLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> } <br /> s y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �'RQPERTY 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 I €Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation -Gravel ..Pack —Depth__of-Gro.ut_Seal <br /> Cathodic Protection ! Rotary. Type of Grout <br /> Disposal ✓c her Ofiidr:Iifformation'. <br /> Geophysica3 � .� Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor J <br /> Type of Pump H.P. 7 <br /> PUMP REPLACEMENT: 1 / / State Work Done <br /> PUMP .REPAIR: ;. / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' Describe Material and Procedure <br /> T 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 'n use. The above <br /> information. is true to t best of my-knowledge and belief. I WILL C OR A GROUT INSPECTION , <br /> PRIOR TO G UTING AN F NAf INS ECTION. <br /> SIGNED TITLE o� <br /> jDRAW PLOT PLAN ON REVERSE SIRE ' <br /> FOR DEPARTMENT USE ONLY _ <br /> PHASE I. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE TI GR INSPECTION PHASE II /FIN INSPECTION <br /> i4 <br /> INSPECTION BY TE INSPkCTION BY ATEA= <br /> 3/76 2M <br /> E H 1426 Rev, 1-74 <br />