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nt Zo SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO Fx CE USE: �fVZ1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7G- 6�f <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOA ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NameGL d ,s �6 r'"I _ ___ Phone <br /> Address � <br /> Contractor's Na se <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/7 RECONDITION f7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP7REPAIR 0 PUMP REPLACEMENT 7 <br /> Other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ t <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL f \ { <br /> INTENDED USE `t 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.. of Well Casing <br /> Domestic/Public Driven Gauge of Casing <br /> k Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary h- 'Type.of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor CS <br /> Type of Pump H•P <br /> PUMP REPLACEMENT: . / / State Work Done ' <br /> PUMP .REPAIR: / State Work Done <br /> DESTRUCTION 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 ona 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..knowled and belief. I WILL CALL ,FOR A GROUT INSPECTI N <br /> PRIOR TO GROUTING AND A FINAL INSPE IO . <br /> TITLE <br /> SIGNEDqm�e t P T PLAN ON MEVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY X6 DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT ANSPECTION PHASE T111FINAL INSPECTION <br /> INSPECTION BY /DATE _ INSPECTION BY DATE <br /> f E H 1426 Rev. 1-74 0 - <br />