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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t (Complete In Triplicate) <br /> i Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> E 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 �✓J l/ `S , 411D CENSUS TRACT <br /> Owner's Name 9e- <br /> Phone <br /> Phone O � —� <br /> Address City <br /> i <br /> Contractor's Name„ License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other K77- <br /> DIS LNCE <br /> / /DISTANCE CO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE bISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r, <br /> Industrial ! Cable Tool Dia, of Well Excavation <br /> 4--Domestic/private ! Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal 1 Other Other Information . <br /> Geophysical - Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _ <br /> / / State Work Done <br /> E <br /> PUMP .REPAIR: / / Slate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth` <br /> Describe Material and Procedure <br /> I hereby agree to comply withtall 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 u <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINA.L 'INSPECTION. <br /> SIGNED <br /> (DRAW:PL T PLAN 'ON REVERSE SIDE) 1: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Ij GROUT INSPECTION PHAS I/FINA,L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �=��7 <br /> E H 1426 Rev. 1-74 3/76 Y <br /> - -� - <br />