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SAN JOAQUIN LOCAL HEALTH DIST TCT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave, ; Stockton, Cale,, <br /> Telephone : (209) 466-6781 k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7/®fll <br /> THIS PERMIT EXPIRES l YEAR FROM -DATE ISSUED Date Issued11-17 <br /> -ll�� (Complete In Triplicate) <br /> Application. is-Te-reby 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 Rules and Regiulati.ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ; CENSUS TRACT <br /> Owner's Name _�' �a�v Phone <br /> Address <br /> Contractor's Name w. License # (137" Phone _j4�i. 76_;7L <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ R'ECONDITION /% DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ _ PUMP REPLACEMENT /_7 <br /> Other /% -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -Y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <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 G <br /> 7� 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractort� � , v � <br /> Type of Pump III AgI <br /> _M H.P. ., <br /> PUMP REPLACEMENT: / / State Work"Done <br /> PUMP .REPAIR: / / - State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ..�. <br /> 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. Within­FIFTEEN 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 kno led e__a.nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND FINAL I <br /> SIGNED ITLE <br /> (WW PL PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f) <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> T` <br /> PHASE II GROUT SPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE" <br /> E H 1426, Rev. - 1-74 6/%� _ 2M <br />