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�oto/o �� �` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OF ICE USE: 1603 E. Hazelton Ave. , Stockton, Calif. . <br /> +�~ (� Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. ,7 <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made 61 the Scan 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 and1the Rules and Regulations of the San Joaquin Local stealth District. <br /> JOB ADDRESS/LOCATION jj CENSUS TRACT <br /> Owner's Name Phone , <br /> Address 7� City <br /> Contractor s Name ' :1 License # �""Phone � <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/? RECONDITION /-7 DESTRUCTION /-7 i <br /> PUMPINSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industriali 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 4 Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor . . <br /> Type ofPump " H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP `.REPAIR: /fC/ State Work Donezx t <br /> a a. L . . . - V <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> .G <br /> I hereby agree to comply withiall 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 1 <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. y ow edge and belief. I WILL CALL FOR A GROUT INSPECTION <br />.FAIOR TO G NG AND A FINAL INS E IO _ i <br /> SIGNED /,'-_ rr---,U LO <br /> .,r. TITLE <br /> � D ,PLOT ON MVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br />,APPLICATION ACCEPTED BY DATE r- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE . I AL INSPECTIO <br /> INSPECTION BY .DATE INSPECTION BY ,` DATE <br /> F E R 1426 Rev: 1-74 r h/75 2M <br />