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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB'; OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Teleprione : (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) F <br /> Application is he made tolthe 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 Ord Iinance No. 1862 and the, Rules and Regulations of the .San Joaquin Local .,Health District. <br /> l CENSUS TRACT <br /> JOB ADDRESS/ _ <br /> - � Phone <br /> Ae- - - <br /> Owner's N 1 �-:i- <br /> City <br /> t <br /> Address ,. �, .. <br /> Contractors Name <br /> License �� Phone����' �Il� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION — DESTRUCTION DESTRUCTION <br /> PUMP MNSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Otheril/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> S FIELD CESSPOOL/SEEPAGE PITHER <br /> SEWAGE DISPOS '.] <br /> PROPERTY LINE-P IVATE DOMESTIC WELL =PUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL . %- CONSTRUCTION SPECIFICATIONS a1 <br /> wCable Tool Dia. of Well Excavation <br /> Industrial � �.�. <br /> Domestic/private 1 Drilled-. .. -.,D.ia. -of..Well-Casing <br /> Domestic/public ;t Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> N <br /> Cathodic Protection l Rotary Type of ..Grout <br /> Disposal Other :Other, Informa_tion <br /> w Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 4_e <br /> Type.of Pump H.P. <br /> PUMP REPLACEMENT: / / (State Work Done <br /> k PUMP REPAIR: / / pState Work Done <br /> r DESTRUCTION 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 /> k 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 knowledg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. �►,/ [' . <br /> SIGNED -(DRAkT PLOT P N REVERSE SIDE) <br /> FOR DEPART NT USE ONLY -4 <br /> PHASE <br /> PHASE 190l�Crh DATE •�-3-7� <br /> APPLICATION ACCEPTED BY IlfST <br /> ADDITIONAL COMMENTS: E PHASE III/FINAL INSPECTION <br /> PRASE II GROUT. INSPECTION DATE <br /> INSPECTION BY iDATE INSPECTION BY <br /> s rPcn9'7a4/,/ 0/77 2M <br /> R 14 1426 Rev. - I-74 <br />