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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> „FOk,OFFICE USE: ' '1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -,/,�J 7 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health Distrit. <br /> .TOB ADDRESS/LOCATION I .+ <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone a <br /> Address <br /> { City <br /> Contractor's Name �-- : . <br /> ..License 4. <br /> - � Phone <br /> . . a <br /> TYPE OF WORK (Check) : NEW WELL MDEEPEN- - <br /> DESTRUCT/ RECONDITION /_/ <br /> _ TON /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 f <br /> Other / / �. <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES gOtj+ PIT PRIVY --� <br /> SEWAGE DISPOSAL 'FIELD �— CESSPOOL/SEEPAGE PIT OTHER <br /> NTENDED USE <br /> PROPERTY LINEAP PRIVATE DOMESTIC,WELL�-h PUBLIC DOMESTIC WELL k <br /> ;ITYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool f j Dia.= of 'Well Excavation �� .�i 1 <br /> Domestic/private Drilled Dia. Well Casing <br /> Domestic/public Driven Gauge of Casing ------ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection T Rotary <br /> Disposal .- Typeof Grout , <br /> 4 Other Other Information <br /> Geophysical �--- <br /> Surface Seal Installed B <br /> ti <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ... <br /> H.P. , <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP .REPAIR: <br /> / / State, Work Done - ! <br /> DESTRUCTION OF WELL: Well 'Di meter r� <br /> Describe Material and Procedure.-- . Approximate Depth <br /> I hereby agree to comply with ag toll Taws and regulations of the .San Joaquin Local Health District <br /> and the State of California per' tainin or regulatin- q <br /> g g well construction. Within FITEEN.•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 putting the well in -use. <br /> information is true to the b The above <br /> t f m owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T NG D A FIN PE N. <br /> SIGNEDa <br /> TITLE jr;V <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY ' DATE <br /> ADDITIONAL COMMENTS: <br /> TM Y ;PHASE II GROUT INSPECTION <br /> pµ PHASE I/F INSPECTION <br /> INSPECTION•BY w DATE- - INSPECTION' BY DATE O- .D- <br /> E H�.1426 Rev_ 1-74 1'� <br />