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__ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 160,'-"9. Hazelton Ave. , Stockton, CaJeN <br /> iTelephone: (209} 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No27-11A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /- <br /> ' (Complete In Triplicate) <br /> pplication is Aereby made to the San Joaquin Local Health District for a permit to construct" <br /> nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JB ADDRESS/LOCATION �" a CENSUS TRACT <br /> inerts Name /l Phone <br /> 1dress �! / � - '� City <br /> ontractor's Name ^ License tz Phone _ —y <br /> 1 <br /> . i <br /> [PE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /' / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> [STANCE 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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation \ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ;. <br /> Irrigation Gravel Pack Depth of Grout Seal Q\ <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> JMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> JMP REPLACEMENT: / / State Work Done <br /> JMP .REPAIR: / / State Work Done <br /> :SiRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material #hd Procedure <br /> hereby agree to comply with all laws and' regulations of the San Joaquin Local Health District <br /> ,.d the State of California pertaining to or regulating well *'construction. Within FIFTEEN DAYS <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ?LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> iformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GYPIG ANDA INAL S <br /> :GNED56 <br /> TITLE_ <br /> ( RAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> 1ASE:"PLICATION <br /> I <br /> CATION ACCEPTED BY DATE <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 3SPECTION BY DATE /✓ INSPECTION BY DATE -F -77 <br /> E H 1426 Rev. 1-74 2 <br />