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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 0 7- /._1 i <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 Jo4quin <br />° County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r i <br /> JOB ADDRESS/LOCATION RAI/4(y CENSUS TRACT <br /> Owner's Name _ fe IP� -77�-s' <br /> e.v rC-er� Phone <br /> Address MA f { 7 city <br /> Contractor's Nam V License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/% RECONDITION'//__7 DESTRUCTION /_7 <br /> PUMP 'INSTALLATION /� PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESjd� YPIT PRIVY "* <br /> SEWAGE DISPOSAL FIELD .-- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 11CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. .of Well -Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 Other' Information p <br /> Geophysical '_.. Surf-ace-Seal=-Installed By— <br /> PUMP <br /> —PUMP INSTALLATION: Contractor <br /> Type of.Pump 7H.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 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO EUXI .G AND A FINAL INSPECTION. <br />, SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , ,. .- _ _. ....... <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT MSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1 7 ` <br />