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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPiiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1.1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S- <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I. (Complete In Triplicate) " <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instar, the work herein described. This application is madet n compliance with San Joaquin ' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI �# <br /> CENSUS TRACT x <br /> Owner's Name / <br /> Phone ` _ 49 41' <br /> Address <br /> City f+ <br /> Contractor's Name <br /> License # � Phoxi 9� <br /> TYPE OF WORK (Check): NEW WELL L DEEPEN/_� RECONDITION /� DESTRUCTION <br /> / <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEME <br /> Other E/ ._N �f <br /> Ir <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> d EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL ELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE " PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OF' WELL PUBLIC <br /> PUBLIC DOMESTIC WELL <br /> CTION SPECIFICATIONS \`l <br /> Industrial Cable Tool Dia. of <br /> 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 Pr-otection Rotary T <br /> Dis osal Type of Grout <br /> p Other Other Information <br /> Geophysical --W----� <br /> Sur ce Seal Installed B : a <br /> PUMP INSTALLATION: 'Contractor <br /> Type. of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: StateF.Work Don ` f <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Describe Material anTPr_0c_e_du_r_eApproximate Depth <br /> I hereby agree to comply with all Taws and regulations of the San Joaquin Local Health District E <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 ING AND A FINAL INSPE IO <br /> SIGNED � <br /> TITLE i <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPANT USE ONLY <br /> PHASE I RT <br /> APPLICATION ACCEPTED BY L` <br /> ADDITIONAL COMMENTS.. , DATE <br /> PHASE II GOT INSPE ION + PHA I FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> r DATE <br /> E H 1426 1 <br /> . Rev, 1-74 <br /> r <br />