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V <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> FOF'OFVICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �r <br /> THIS PERMIT EXPIRES ,I YEAR FROM DATE ISSUED Date Issued' <br /> (Complete In Triplicate) <br /> Applicatiod 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 /> f <br /> r <br /> Owner's Name Phone <br /> Address City <br /> �� �� o <br /> Contractor's Name Licenselz <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL /j,�DEEPEN / RECONDITION /—/ DESTRUCTION /- <br /> PUMP INSTALLATION 14-r PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 4 ` SEWER LINES _ PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD /j�-a 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 �f <br /> x x Domestic/private Drilled Dia, of Well Casing _ T <br /> Domestic/public Driven Gauge of Casing 72o7 ' <br /> Irrigation Gravel Pack Depth of Grout Sear p <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 .P. . - <br /> PUMP REPLACEMENT: / / State Work' Done <br /> PUMP .REPAIR: / / State Work Done ` . <br /> DESTRUCTION OF WELL: Well Diameters " - Approximate Depth <br /> Describe Material and-Procedure <br /> I hereby agree to comply with all laws and 'regul.ations of the. San Joaquin Local Health District � <br /> E. 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 thewell 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 GROU.. IN AND A FINAL INSPECT ION <br /> SIGNED ;.TITLE _ --- <br /> (DPAW PLOT' PLAN ON REVERSE SIDE) <br /> FOR-°DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ITI/FINAL INSPECTION <br />" INSPECTION BY DATE ti. • , +' INSPECTION BY DATE <br /> 3 b/77 _ 2M - <br /> E H1426 Rev- . 1-74 <br />