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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FO&.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18b2 and the Rules and Regulations of the San JoaquinLocal Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ?-oS 070-YO <br /> Owner's Name Phone � - 412 <br /> Address A <br /> City <br /> Contractor's Name �-� <br /> License # ', hone '.C9 <br /> TYPE OF WORK (Check): NEW WELL /_7� DEEPEN /X7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR -/� PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKb , SEWER LINES > PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SgEPAGE PIT OTHER <br /> PROPERTY,LINE -- PRIVATE ]DOMESTIC WELL" PUBLIC DOMES IC WELL <br /> INTENDED USE TYPE' OF' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ',' Cable Tool Dia. of Well Excavation v <br /> Domestic/private 't Drilled �� � ,Dia: `af Well Casing � <br /> Domestic/public Dr vex . ..: Gauge�of Casing E <br /> Irrigation Gravel Pack ""Depth-of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information': <br /> Geophysical ta.____,� Surface Seal Installed B <br /> k <br />-PUMP INSTALLATION. Contractors, E <br /> .Typeof•-.Pump; <br /> PUMP REPLACE / State Work Done <br /> .._.� �.._.�:. ..._ ...... .. ..,.�. . ... �,_ - . __..�,_..T - -. <br /> . .. / , f• � L �.`, <br /> PUMPtREPAIR: / ,/ State Work Done. <br /> IIES•TRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin aquin 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 puttiing.-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 <br /> ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE 'SIDE 4 <br /> FOR DEPARTMENT USE.ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHOMLMNAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION $ DATE <br /> .77 <br /> E H 1426 Rev. 1-74 h/75 2M <br />