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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0RIOFFI� CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a _/ f'la <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Issued -F- <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a�7 X 7 7,( 4 do CENSUS TRACT <br /> Owner's Name Phone <br /> Address S Q -e, City 1,rX0—< ► <br /> Contractor t s Name e, License # 46 72J Phone 4Z4 Z 74, 24 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/? RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION // PUMP REPAIR �& PUMP REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY II <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT :'OTHER /r V <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 <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. ti✓ <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP :REPAIR: State Work Done _ all J146 <br /> E&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-beat.of owl d 0---Li belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A PTATAT INSPECTION <br /> SIGNE TLE <br /> D LOT LAN ON REMRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ! �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE `, <br /> E H 1426 Rev. 1-74 1-74 2M <br />