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SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> FOF OFFICE USP 1601 E. Hazelton Ave. ,__Stockton, Calif. <br /> Telephone: (209) 466-478l <br /> 9" APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,, 7Lt� i <br /> t <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. 1862 anId -the Rules and Regulations of the San Joaq i Local Health District. <br /> JOB ADDRESS/LOCATION - Q(JO� CENSUS TRACT <br /> • J <br /> &5 Phone ���- `� <br /> Owner s Name C- <br /> Address City <br /> Contractor's Name License # Phone .�2_ <br /> TYPE OF WORK (Check) : NEW WELL /i?'DEEPEN/ / RECONDITION / / DESTRUCTION /7 <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 Hyl <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation '` <br /> Domestic/private Drilled Dia. of Well Casing <br /> - - Dome-stic/pub-1-cm -Dr-ivn .� --= Gau.g&-of_C-as <br /> Irrigation ��.�^ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection E/ Rotary Type of Grout <br /> Disposal Other Other Information . _ <br /> f _ Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-.REPAIR: / / ,;; State Work Done <br /> DESTRUCTION OF WELL: We11- Diameter E Approximate Depth <br /> y <br /> Describe Material and Procedure <br /> N <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 /> WALL 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 G OUTING AND A FI INSPWTION. ? <br /> SIGNED <br /> ITLE ' <br /> DRAW P T PLAIV O�RERSE SIDE) 1` <br /> FOR PARTMENT USE ONLY ' <br /> PHASE IAeg,1-7,< <br /> - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHAS I I/ N INSPECTIO <br /> INSPECTION BY - DATE INSPECTION BY DATE77, <br /> pf- <br /> 3 76 2M <br /> E".H 1426 Rev. 1-74 d <br />