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nn SAN JOAQUIN LOCAL HEALTH. DISTRICT G <br /> FOE OFFICE USE: 4� 601 E. Hazelton Ave. , Stockton, Calif. <br /> Vv Telephone: (209) 466-6751 <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) <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 d the �Rules and Regulations of the <br /> S�an� JJoaNCE <br /> ocal Health District. <br /> JOB ADDRESS LO `� `� `'�`���� US TRACT <br /> Owner's Name Phone � v 7 <br /> Address City <br /> rte- <br /> Contractor's Name �� ` UIS License <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /_7 'DEEPEN�/_7_ kECONDITION % / DESTRUCTION -/_7 - - <br /> PUMP INSTALLATION / / PUMP REPAIR /v PUMP REPLACEMENT /� <br /> Other /_7 <br /> 7-�, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> --_ <br /> PROP <br /> ._ —. --_-- _ --„--- PUBLIC DOMESTIC WELL <br /> INTENDED USE, <br /> -- <br /> PROPERTY LINE PRIVATE DOMESTIC WELL <br /> 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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> — <br /> PUMP -REPAIR: State Work Done <br /> 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 /> 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 FOR A GROUT INSPECTION., <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D PLAN 'ON REVERSE SIDE <br /> It DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � ` <br /> ADDITIONAL CONM$NTS: <br /> PHASE ItAER E ON PHASE III/FINAL INSPECTION <br /> INSPECTION BY TE INSPECTION BY DATE /l � <br /> E H 1426 Rev. 1-•74 7-W lN,�i'U � J��.G��t �[.�.n�”to G�-�� 306 2w <br />