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SAN JOAQUIN LOCAL HEALTH DISTRICT , -- <br /> S <br /> FOR;OF'FICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 Telephone: (209) 466-6781 <br /> i' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> . THIS PERMIT EXPIRES 1•YEAR .FROM DATE ISSUED Date Issued �6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Llealth District for a permit to construct <br />'k and/or install the.work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 a;d the Rules and Re ulations of the San Joaquin Local Health District. <br /> 1 <br /> ; <br /> JOB ADDRESS/LOCATION CENSUS TRACT. <br /> Owner°s Name Phone <br /> Address 6 - City; _� ✓ , — <br /> License c�0014d� <br /> pp.. <br /> Contractor's Name -� <br /> Phone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/_T RECONDITION /_—T_ DESTRUCTION �T <br /> PUMP`INSTALLATION /� PUMP REPAIR /� PUMP REPLACEMENT <br /> other I I <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 /> M Industrial Cable,.Tool Dia. of Well Excavation <br /> 1 E Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public, Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 4� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMF INSTALLATION; Contractor ald <br /> Type; of Pump H.P. %�' <br /> �. <br /> PUMP REPLACEMENT / State Work Done: <br /> PUMP '-REPAIR: / / State Work Done - <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 /> f information is true to the best-of- my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GRPUTING AND NAL T19SPECTION. <br /> SIGNED TITLE14 <br /> iRAW PLOT PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> t PHASE I <br /> s APPLICATION ACCEPTED BY DATE �O <br /> ADDITIONAL COMMENTS: <br /> PHASE I G U INSPECTION PHASE II7 FIN NSPECTI N r. <br /> INSPECTION BY INSPECTION BY ATE <br /> t E H 1426 Rev. 1-74 1-74 2M _ <br />