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_ .� 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y FO OFFICE USE;" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-,-?- <br /> THIS <br /> -S <br /> E <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -� <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 Joaquii <br /> County Ordinance No. 1862 and, the Rules and Regulations of the San Joaquin Local Health District. <br /> F JOB ADDRESS/LOCATION Z _ <br /> J�Zlt,' ��ENSUS TRACT <br /> Owner's Name p <br /> Phone �� 7 <br /> Address <br /> 4 City it <br /> ,Contractor's Nameof <br /> ; <br /> [ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEZL <br /> INTENDED USE TYPE OF WELL <br /> IndCONSTRUCTION SPECIFICATIONS <br /> ustrial Cable Tool Dia, of Well Excavation fe <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing JJ <br /> i Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic .Protection Ro-tary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _f- <br /> _,_1 __ <br /> ` Surface Seal Installed B <br />' PUMP INSTALLATION.:," Contractor 4 <br /> Type of Pump <br /> H.P. <br />":.PUMP.REPLACEMENT:. * / / State Work Done; <br /> PUMP .REPAIR: / / State Work Done T <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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...aLs <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. <br /> I WILL CALL FOR A GROUT INSPECTION t <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED- <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)Q � -° . ...,.. <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED -BY21 <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE i x 4 <br /> E H 14 2 6 <br /> _ Rev. - 1'74 <br />