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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: (/ ; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i 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 /> I (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 R and Regulations of the San Joaquin Local Health District. <br /> 1 <br /> JOB ADDRESS/LO ATION CENSUS TRACT <br /> k Owner's Nam - ' <br /> Phone, <br /> f " <br /> Address 4P, , City <br /> Contractor's Name Lice9a373 'ho ��y�` <br /> s <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECON-bITION /-7DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGt PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .industrial 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private S Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 9�'r <br /> Irrigation Gravel---P-a--k=- -wept-h-of <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal i Other Other Information ' <br /> Geophysical Surface Seal Installed By: i <br /> (- <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Don <br /> P <br /> .PUMP--REFAIR:t. :-:., .J„�/��State-Work-Done--.— <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> y <br /> .—� �.. PP P <br /> Describe Material and Procedure j <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 t <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 be"st of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE . ' <br /> DRAW Ph it PLAN•'ON REVERSE SIE) f; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3-1,F-7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE I OUT INSPECTION PHASE, I FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 3/77 <br />