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S <br /> W T. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 4 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7o. gy <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued�6^114,7,04 <br /> La1V <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 Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Lli CENSUS TRACT <br /> b <br /> Owner's Name Phone ' <br /> 7 F: <br /> Address // City <br /> Contractor's NameLicense Phone <br /> i TYPE OF WORK (Check) : NEW WELL "/77-- DEEPEN -/_7 -7RECONDITION / DESTRUCTION "/-J <br /> PUMP INSTALLATION /v/'PUMP REPAIR/-7—PUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO- NEAREST: SEPTIC TANK / t3 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 WELT. CONSTRUCTION SPECIFICATIONS <br /> Industrial L-----Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ' Driven Gauge of Casing {:] <br /> Irrigation �w Gravel Pack Depth of Grout Sea �— <br /> Cathodic Protection Rotary Type of Grout " <br /> Disposal Other Other Information " <br /> k Geophysical ' Surface Sea] Installed 'B r\ <br /> y <br /> J <br /> PUMP INSTALLATIONS Contractor <br /> Type .of Pump A.P. " <br /> PUMP REPLACEMENT: . / / State Work Done <br /> ' <br /> PUMP ,REPAIR: / / :State Work Done . <br /> DES-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 puttingthe -well- in-use.—The above <br /> information is true to the-best"oE my knowledge and belief. I WILL CALL FOR A "GROUT INSPECTION <br /> PRIOR TO GRD IN AND A FINAL INSP N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> [ APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PAASE-IIIIFIVAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE z _ <br /> TT <br /> E H 1426 Rev. 1-74 otu <br />