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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'OE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THId PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedAN18 1978 <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 hereinidescribed. This application is made in compliance with San Joaquin i <br /> County Ordinance No. 1862 and the Rules and Regulations of the an Joaquin Local Health District. <br /> JOB ADDRESS/ <br /> LOCATION / '� CENSUS TRACT <br /> Owner's Name Phone C <br /> k <br /> Address . . f City <br /> Contractor s Name s <br /> License �� � � Phone <br /> t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION ./_/~, DESTRUCTION <br /> PUMP IN ALLATIO / / PUMP REPAIR /:.,/ P R LAS NT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-PITT OTHER + <br /> PROPERTY' LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i4 CONSTRUCTION SPECIFICATIONS <br /> Industrial III Cable Tool Di'a.- of We-1.1-Excavation <br /> Domestic/private 1 Drilled Dia. -ofTWell Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation 1 Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical I Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />. PUMP REPLACEMENT: / / Sate Work Done <br />' PUMP -.REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br />, I hereby agree to comply withlall laws and regulations bf the San Joaquin Local Health District <br /> and, the State_o California�pertaining__t.a or_regulating;well construction. Within FIFTEEN DAYS <br /> -- - <br /> after completion of m work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRIL'LERS�'REPORT of-the well -and'ziotify them before putting-the well-in use:=^Th ~ abvve <br /> kinformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />!PRIOR TO GROUTING A INAL.INSP CTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY / <br /> i PHASE IDATEX76 <br /> ,APPLICATION ACCEPTED BY c <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - v <br /> ._.r . <br /> 1177 . _ 2 <br /> E H 1426 Rev. 1-74 t' <br />