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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFF10E USE: 1601 E. Hazelton Ave. , Stockton, Cali . <br /> Telephone: " (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 � <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z ��-7� <br /> (Complete Iri1riplicate) <br /> Application is hereby made to the San Joaquin Local _Health: DiStrict fora permit tc construct <br /> end/or install the work herein described. This application,is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations,-of.%the 44.ioaquin..Local Health District. <br /> JOB ADDRESS/LOCATION ��� I ��;�� k f f�.�� � cEN$t)5 TRACT <br /> P Phone <br /> r Owners Name <br /> Address City.. <br /> Contractor's Name License #?-o 7 Phone d-0 9 <br /> I TYPE OF WORK (Check): NEW WELL DEEPEN/7 -RECONDITION /7 ..DESTRUCTION f7 <br /> PUMP INSTALLATION ./7 PUMP REPAIR /_7 PUMP REPLACEMENT �T , <br /> Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/.SEEPAGE_PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELIr� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /2.11 <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /7 State Work Done - <br /> I PES'TRUCTION 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 CALL FORA GROUT INSPECTION <br /> PRIOR TO RPUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN-ON REVERSE SIDAIL9. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> -ADDITIONAL COMMENTS: 7 <br /> PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r 't E H 1426 Rev. 1-74 1-74 2M <br />