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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�,OF 'ICE USE: 1603 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No."l -S- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made toithe 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. 1862 and1the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `C <br /> CENSUS TRACT <br />'Owner's NameEll <br /> Phone 6%3 <br /> Address ' <br /> city . <br /> Contractor's Name � . License <br /> Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN ,V RECONDITIO /7 DESTRUCTION <br /> PUMP INSTALLATION /— <br /> / / UMP REPAIR - PUMP REPLACEMENT I? <br /> Other /. / <br /> DISTANCE TO NEAREST: SEPTIC TANK --?ASEWER LINES <br /> PIT PRIVy- <br /> SEWAGE DISPIELD CESS 4P OL/SEEPAGE PIT, OTHER <br /> PROPERTYtLINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />- Jz Domestic/private 1 Drilled Dia, of Well Casing 4 <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout . <br /> Disposal t Other Other Information <br /> Geophysical -�^ Surface Seal Installed B <br /> y. <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT / / Staite Work Done <br /> I � <br /> PUMP .REPAIR: t <br /> • State Work Done i <br /> DES.,TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> i . <br />[-'hereby agree to comply with al I l.awsiand regulations of the San Joaquin Local Health District <br />:nd the State of California' pertaining' to or regulating well "construction. Within FIFTEEN DAYS <br /> tfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting-the.-well in-use.. The above <br />'.nformati is true to the best' o€ my..knowledge and belief. 1 WILL CALL FORA GROUT INSPECTION <br /> RIOR TO OUTING AND FIN of <br /> CTION. <br /> iIGNED E�� <br /> TITLE <br /> 9 e_V/JLJO�jON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> 'I <br />•PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: TE <br /> PHASE II GROUT INSPECTION P INSPECTION <br /> NSPECTION BY _ ^� DATE INSPECTION BY` — <br /> DATE <br /> E H 1426 Rev. 1-74 <br />