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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: . 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone u. (0)9) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNS.' PERMIT Permit No. �9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Pate.Issued _L2�-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 the. Ru.les and Regulations of the San Joaquin Local Health .District. <br /> JOB ADDRESS/LOCATION /l{�- �'4 /(/ CJS=CENSUS TRACT <br /> Owner's Name Phone <br /> Address G 7 City <br /> Contractor's Name <br /> . License# Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEP_ENJ,/_/ RECONDITION I_/ DESTRUCTION f_T <br /> PUMP INSTALI.ATiON�/z/ 'PUMP REPAIR I / PUMP REPLACEMENT <br /> Other / / f. a <br /> • J I <br /> DISTANCE TO NEAREST: SEPTIC TANK �!_ SEW-ER NINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD " GESSPOOL/-SEEPAGE PIT OTHER <br /> PROPERTY LINE. - PRIVATE DOMRSTIC-WELL"` PUBLIC DOMESTIC WFLL <br /> INTENDED USE ICATIONS t r <br /> IndustrialCahle Tool Dia. of Well Excavation � <br /> i <br /> Domestic/private Drilled _ 4 Dia. .of knell Casing- _ `' <br /> Domestic/public Driven Gauge of Casing fel <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 's Rotary Type of Grout <br /> Disposal Other Other Information i <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done i <br /> xPUMP -.REPAIR: / ,I ,State Work alone .; <br /> DT S. OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> AI hereby agree- CE.complywTa th all laws and regulations of the San Joaquin Local Health District <br /> - <br /> and the State of,Ca1i'forriia pertaining to or regulating well construction. Within FIFTEEN DAY <br /> after completion of my workona-ii -well,,I will furnish the San Joaquin Local Health District a <br /> WELL .DRILLERS REPORT of the Wel-l_gnd notify them before putting the- well in use-... The above <br /> information is true to the best of- y�knowledge and belief. 1 WILL—CALL FOR A GROUT INSPECTrON <br /> PRIOR TO GR UTING ANR A NAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLANION REVERSE SIDE) <br /> FOR DEPARUMENT USE ONLY <br /> r PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS- <br /> PHASE II GROUT INSPECTION r�THASE..II FINAL INSPECTION <br /> INSPECTION-BY _ DATE INSPECTION BY DATE <br /> n 2M <br /> E H 1426 . Rev. •1--74- <br />