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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: .1.601 E. Hazelton Ave. , Stockton, Calif. <br /> t 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 /> (Complete In Triplicate) s <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 and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION, `fir 3_g _ ;3 n C7 CENSUS TRACT <br /> /' �d� <br /> Owner's Name - �•CJ <br /> Phone <br /> f <br /> Address City <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK Check NEW WELL/ / <br /> DEEPEN RECONDITION RECONDITION_/ / DESTRUCTION <br /> (Check) : <br /> PUMP INSTALLATION I I PUMP REPAIR '/ I PURR' REPLACEME I�T <br /> Other f / <br /> DIST CE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE.PIT OTHER <br /> OPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL a <br /> INT9MMIj USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (1� <br /> Industrial t Cable Tool Dia, of Well Excavation rR� <br /> Domestic/private ? Drilled Dia. of Well Casing nW <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation A Gravel Pack Depth'of Grout Seal ter` <br /> Cathodic Protection Rotary Type of Grout <br />` Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br /> t Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / Mate Work Done <br /> DESTRUCTION OF WELL: Well Aiameter � Approximate Depth <br /> Describe riarand Procedure i- <br /> I hereby agree to comply withf1 laws and degul o of the San Joaquin Local Health District <br /> and the State of California peaining to or re ulating 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 OUTING AND A FINAL INSPECTION. <br /> SI ED TITLE <br /> DRAW PI: T PLAN 'ON REVERSE SIT3E) ; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL COMMENTS: <br /> PHASE II .GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> y INSPECTION BY DATE INSPECTION BY 2 DATE -�, 7 9 __ <br /> . 7b <br /> 2M <br /> E H 1426 Rev. 1-74 <br />