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:� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FORIOPFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> trinstall <br /> (Complete In Triplicate) d0?- n1a- �Appln' is hereby :Wade to the San Joaquin Local Health District for a permit to construct <br /> and the work herein described. This application is made in compliance with San Joaquin <br /> County -Ordinance No 1862 and jhe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> 3 ' <br /> Owner's Name Phone <br /> Address C? d 3 U City , <br /> Contractor's Name License Phone <br /> ' O <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN -/-7 RECONDITION /-7 DESTRUCTION /- a <br /> PUMP INSTALLATION / / —PUMP REPAIR -PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> •14 �-._ - SEWAGE DISPOSAL FIELD "� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMEL 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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump fl P. <br /> PUMP REPLACEMENT: f-1 State Work Done <br /> PUMP ,.REPAIR: kv State Work Done&�f 1 J <br /> ES•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 FOR A,GROUT INSPECTION <br /> PRIOR TO GROU NG AND A ENAL INSPECTION. <br /> SIGNED TITLE <br /> )(DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR PEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> � 4µ <br /> 4 E H 1426 Rev. 1-74 1-74 2M <br />- - - - <br />