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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.7OFFICE USE: 1601 E. Hazelton. .Ave. , Stockton, Calif. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No..;7 7'- 3_; A' <br /> THIS PERMIT EXPIRES i YEAR FROM DATE -ISSUED Date Issued7j <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address < v City , <br /> Contractor's Name License #, � Qp Phone <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN 17 RECONDITION /7 DESTRUCTION f7 <br /> 1. PUMP INSTALLATION PUMP REPAIR/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT 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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal - Other Other Information ' { <br /> Geophysical Surface Seal Installed 'B : �I <br /> PUMP INSTALLATION: Contractor j <br /> Type .of Pump A.P. <br /> PUMP REPLACEMENT: .. � State Work Done � �'.,.,P <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby aEree 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 i <br /> WELL DRILLERS REPORT of the well and notify them before puttin,g.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 Mp <br /> ,,A Pig& I ECTION. <br /> SIGNED 2ZIdEr TITLE ,© �r_ � ��� <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE"".- 7 <br /> 4DDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE IIIIFZNAL INSPECTION <br />(' INSPECTION BY DATE INSPECTION BY DATE -� <br /> E H 1426' Rev. 1--74 r. . h/75 2M ; <br />