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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: i 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � /„/� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N ��— <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue47 <br /> (Complete In Triplicate) <br /> Application is hereby Ide to the San Joaquin Local Health District for a permit to construct <br /> k and/or install the workherein described. This application is made in compliance with San Joaquin <br /> `62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 18' <br /> �I <br /> JOB ADDRESS/LOCATION JI CENSUS TRACT <br /> ���• Phone <br /> fOwner's Name !F <br /> /Q City <br /> k Address <br /> Contractor's Name <br /> I� License � �'6�. Phone ' ��_ d <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /r/ DESTRUCTION /_7PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other '17 <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ----'PIT PRIVY_ <br /> SEWAGE DISPOSAL FIELD. CESSPOOL/-SEEPAGE PIT OTHER <br /> PROPERTY LINE '',PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 4, CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE.-.- TYPE OF WELL <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private' Drilled F Dia. of Well Casing <br /> omestic/public Driven # Gauge of Casing <br /> rigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical y ; Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor } <br /> P. <br /> Type of Pump ' <br /> hState Work Done, <br /> PUMP REPLACEMENT: / / <br /> PUMP .REPAIR: / / State Work Done-. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> �:l <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local District <br /> Health <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 <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 CAL OR A GROUT INSPECTION <br /> PRIOR TO OUTING ADUY-N FINAL IN PE EON. <br /> SIGNE TITLE <br /> DRAW POT- PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY gr <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: : PRA I/FIN L INSPECTION <br /> PHASE*.- ROaUT INSPECTION DATE 7INSPECTION BY DATE INSPECTION BY <br /> 3/76 2M <br /> E H 1426 Rev. 1N-74 - - - - <br /> F <br />