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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_K70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;_7d-1_Y6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -2 _7J' <br /> (Complete In Triplicate) <br /> Applica ion is hereby made to the Sen Joaquin Local 11calth 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 les and Regu ations of they San Joaquin Local Health District. <br /> JOB ADDRE OCATION 1� ' CENSUS TRACT <br /> Owner's l ��� Phone <br /> Address Cit <br /> Contractor's Name License # 3�5hone 4,-116G <br /> TYPE OF WORK (Check) : NEW WELL J-7 DEEPEN/7 RECONDITION /-7 DESTRUCTION /7 D <br /> PUMP INSTALLATION /-7 PUMP REP IR 777PUMP LACEMENT J? (V <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 <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 , <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:-... State Work Done AD <br /> PUMP '.REPAIR: State Work Don ✓ <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 INSPIJCTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHks&i FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r 4/75 2m <br />