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U SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —;,?OF,-"OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES I 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 Ordina,ccee No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> !3 #* a6 <br /> JOB ADDRESS/LOCATI N �. CENSUS TRACT <br /> Owner's Name <br /> � -C� � Phone <br /> Address �,�� ��, City A <br /> Contractor's Name License 4,,A4�' phone - � <br /> � iry <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN -/ / RECONDITION / / DESTRUCTION /- F <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing W <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 Information f <br /> Geo" h sical <br /> P Y Surface Seal Installed By: <br /> PUMP INSTALLATION:« - Contractor <br /> Type: of Pump H.P. .. <br /> PUMP REPLACEMENT: : State Work .Done /�,i <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 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 GROUTING .AND ApFINAL INSPE <br /> SIGNEDTITLE �I <br /> (DRAWPi, ' PLAN '0 RE ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> /' PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION Fit <br /> INSPECTION BY DATE INSPECTION BY DATE T�`' �� '77 _ + <br /> E H 1426 Rev. 1-74 ' <br /> 3/76 2M <br />