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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: I&d 1601 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 <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 Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name r, <br /> Phone <br /> Address � � °'� � Cit ~ ' <br /> Contractor's Name �i <br /> /7 License # 2/�xe4hone <br /> f / <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /7 DESTRUCTION /•7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP- REPLACEMEN-T— <br /> Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYtLINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A Cable 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 t/1 <br /> Geophysical Surface Sea] Installed B <br /> PUMP INSTALLATION:' ' <br /> Contractor <br /> Type of tfPump H.P, . . <br /> i <br /> PUMP REPLACEMENT: -)) State Work Done <br /> J VS4/h. <br /> PUMP �REPAIR: <br /> / / State Work Done . <br />)ES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe. Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health istrict <br /> tnd the State of California pertaining to or regulating we11 'mconstruction. Within FIFTEEN DAYS <br /> tfter completion of my work on.a new well, I will furnish the San Joaquin Local Health District a <br /> JELL DRILLERS REPORT of the well and notify them before putting. the .well in use. The above <br />.nformation is true to the best! of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO G TING AND A F NAL IN PECTION. <br /> SIGNED s TITLE(DRAW PLOT PLAN ON 4 <br /> REVERSE SIDE <br /> ' *IF <br /> I FOR DEPARTMENT USE ONLY <br />'RASE I <br /> APPLICATION ACCEPTED BY DATE 2as--? <br /> J)DITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION I <br /> /FINAL INSPECTIO ; <br />.NSPECTION BY 'DATE INSPECTIONBY DATE i <br /> _ Y k <br /> E H 1426 Rev. 1-74 1177 2M <br />