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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> BOE OFFICE USE: 1.601. 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 -5 �� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct i <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 o� �3SUS TRACT ' -- <br /> Owner's Name Phone <br /> Sy <br /> Address - - City <br /> o� , <br /> Contractor's-Name � License h <br /> ��-�-�-`�-� aneg <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ()C9 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 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 =Excavati.on <br /> 'Domestic/private Drilled )Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack `Depth of Grout Seal. o � <br /> Cathodic Protection �Rotary Type of Grout ,ri - <br /> Disposal Other Other 'Information'-- <br /> Geophysical Surface Se&I;,Installed By: -`�i <br /> ! A t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP, REPLACEMENT: / / State Work Done , <br /> PUMP ,REPAIR: / / State Work Done e <br />, DESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material. and Procedure <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I F c <br /> APPLICATION ACCEPTED BY DATE L5--5 76-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I PECTION PRASE IIS/FI AL INSPECTION j <br /> INSPECTION BY 0 DATE �- INSPECTION BY DATE <br /> 4 E'H. 1426 Rev. - l-74 - _� <br />