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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 160.1 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 1 YEAR FROM DATE ISSUED. Date Issued/ :27-7 <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/LOCATIONoe CENSUS TRACT <br /> Owner's Name <br /> 'too- <br /> Phone <br /> Address ��-- <br /> City'' ( -- <br /> Contractor's Name License # <br /> -feQ� Phone ^ <br /> TYPE OF WORK (Check) : NEW WELL / ,/ DEEPEN I I RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION _/_/ PUMP REPAIR / / � PUMP REPLACEMENT <br /> Other / / j <br /> DISTANCE TO NEAREST: SEPTIC TANK---:o ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEI'RIVATE DOMESTIC WELL —. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i- CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Toole Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing W <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 : r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> fl.P. f <br /> PUMP REPLACEMENT: / / State Work 'Don <br /> State=Work Done--- <br /> - <br /> one,. . s �.._..� <br /> D.ESTRUCTION OIWELL:` .: Well Diameter <br /> 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 the. well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL C LL FOR A GROUT INSPECTION <br />'RIOR TO GR91WING AND INA INS�ECTON, <br /> 5IGNED <br /> TITLERAW PLOT PLAN ON REVERSE SIDE) �-- <br /> CHASE I FOR DEPARTMENT USE ONLY f� <br /> APPLICATION ACCEPTED BY DATE �C/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPEC410N PHASEy4jJFINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> :?Z2j&/ <br /> E H 1426 Rev- 1-74 _ _ /7 <br />