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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nd.' J <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 pert 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 pndjP)egulatAwfj of the San Joaquin Local Health District. <br /> a <br /> JOB ADDRESS/LOCATIO <br /> J CENSUS TRACT <br /> Owner's Name <br /> Z <br /> Phone XS 7 <br /> Address 2 xo_� Cit <br /> Contractor's Name �,�e-�t� <br /> _ Licence #142-37-3 Phoae3 6 .� <br /> -�'-PE-OF..WORKr(-Check):--.NEW WELL.:/? DEEPEN /_7 RECONDITION /_7 DESTRUCTION-/_f <br /> PUMP INSTALLATION I J PUMP REPAIR PUMP REPLACEMENT /7 I <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domesti8'/private Drilled Dia. of Well Casing i. <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- <br /> Geophysical <br /> nformationGeophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /./ State Work Done t <br /> PUMP !REPAIR:.- ' ¢ State Work Done <br /> ,SES TRUCTION 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 /> 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 knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUT G AkJD A FINAL INSPECT N. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE O <br /> U <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r <br /> { E H, 1426 Rev. 1-74 <br />