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I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrONICE USE: 1601 E. Hazelton Ave.., Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit. No.. .�s_, c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSU'Eb Date„ Issue _-I /f- � <br /> (Complete In Triplicate) A <br /> Application is hereby made to the San Joaquin Local Health Distritt fdth�a' permi.t o conistruct <br /> and/or install the work herein described. This application ris.made, in.-tompliancdwi <br /> ` th_San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations.-of the —San''eJoaqu in°�Lbca ;Healih'District:. <br /> f JOB ADDRESS/LOCATION CENSUS TRACT : . <br /> f <br />{ Owner's Name Phone <br /> jAddress i - _ __ . .ti,. �..-. - City <br /> k Contractor's Name License # ,r) j Phone z'1 , <br /> TYPE OF WORK (Check): NEW WELL '/K DEEPEN I-7 RECONDITION /-7 DESTRUCTION /7 <br />€;. PUMP INSTALLATION / PUMP REPAIR / / . PUMP REPLACEMENT <br /> E Other <br /> DISTANCE TO NEAREST: SEPTIC'TANK 6j9 SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL SE PAGE PIT OTHER . , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL''- . PtMLIC DOMESTIC WELL <br />€ INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> t Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private s Drilled Dia. of Well: Casing <br /> Domestic/public E Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal 1-0 G`l <br /> Cathodic Protection 1 �L Rotary Type of Grout <br /> Disposal ' 1 Other Other Information <br /> GeophysicalIZ- <br /> Surf ace Seal Installed By: <br /> 1 PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP;,.REPAIR: /7 State Work Done <br /> I � <br /> PES4RUCTION 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 k on a new well, I will furnish the;,-San Joaquin Local Health District a <br /> WELL DRILLERS REPO of the well and notify them before putting..the..well in-use.. The above • <br /> information 'I <br /> to the-best of my .kn ledge and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G �iND Cr. � <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE DE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I l <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: ^j <br /> PHASA GROUT INSPECTION PHAS&j:X&/FINA& INSPECTION <br /> INSPECTION BY 4j1A TE / _ Ir— W INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 o- 1-74 ZM <br />