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{ SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> FOE!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 3rJ 7� <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 pthe Rules and Regulations of 'he San quin Local Health District. i <br /> JOB LOC <br /> ADDRESS ATI a <br /> / _ ..�� �....... ..........,,_ — CENSUS TRACT <br /> Owner's Name t - - /�i Phone <br /> Address Q City <br /> Contractor's Name License ##c�`1 �0 Phone6�7_ l <br /> I <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN -/-7 RECONDITION /- DESTRUCTION I' I <br /> PUMP INSTALLATION / PUMP REPAIR RUMP REPLACEMENT %7 <br /> Other <br /> d <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -•4 <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 i 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 C <br /> Disposal Other Other Information <br /> ! Geophysical Surface SeAl Insta B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done V <br /> PUMP ,REPAIR: /-7 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 /> information is true to the-best-of- my-knowledge and belief. I WILL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING A INSPECT,10N.0 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P FINAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> + µE H 1426 Rev. 3-74 7_74 2M ' <br />