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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone : (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '--�t _ <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION wf ANSUS TRACT <br /> ti <br /> Owner's Name Phone ,`'' <br /> Address City <br /> Contractor's Name J T License AF Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT ' <br /> Other <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 r 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.— ..,,�.,�. ,�.._ �� �., _Y.� 4Surface•. Sea] ...Instal-led. - <br /> I., <br /> PUMP INSTALLATION: JContracto- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / ./ State Work Done4 "lei <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 C FOR A GROUT INSPECTION <br /> PRIOR TO WUTING AND INSPECTION. e <br /> SIGNED CtA, TITLE <br /> (DRAWPLDT PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO T INSPECTION PHASE II FINAL NSPECTION / <br /> INSPECTION BY DATE INSPECTION Z6 b ; <br /> E H 1426 -Rev. 1-74 - c� 3/76 2K <br />