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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> 'Telephone: (209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ha,2 -, <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local fleal,th 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 L+ CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> . City . . <br /> Contractor's Name ..C.s- License # Phone 41C4-06.%- 4 <br /> _4 <br /> TYPE E OF WORK (Check) : NEW WELL /_7 DEEPEN RECONDITION /H DESTRUCTION <br /> PUMP INSTALLATION /—/—PUMP PUMP REPAIR /7 PUMP REPLACEMENT /? <br /> AL <br /> Other j/7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP '.REPAIR: /% State Work Done <br /> Ep 5�T�RUCTION OF WELL: Well Diameter 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 j� <br /> PHASE ]C DATE �2 J <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS• <br /> PHAS II GROUT INSPECTION PHASE III F IN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3 E 'H .1426 Rev. 1-74 <br /> 1-7 4l2M <br />