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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1,601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: 209 466-6781 ,- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71�-36 <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 Joaquin <br /> County Ordinance No. 1$62 and th6'Rules and Regulations of the San Joaquin Local Health District + <br /> JOB ADDRESS/LOCATION SOSd � R.,,,4v tv CENSUS TRACT <br /> Owner's Name Phone <br /> Address City r <br /> Contractor's Name '� _ License # Phone �� <br /> TYPE OF WORK (Check) . NEW WELL/_7 DEEPEN _7 RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /-7 <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 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 4:.{ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:'. / / State Work Done 1 <br /> UMP — _ 1 <br /> P 'REPAIR': <br /> . �/� S'ta'te'�Work""Do"ne <br /> DESTRUCTION OF WELL: Well Diameter 'L �rs� <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. 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> lkrs; <br /> DRAW PLAN 'ON RE RSE SI1�E —"� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYE <br /> DATE j`.� <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT iNSPECTION PHASE III FINAL INSPECTION . { <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 V76 _ <br />