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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t FOF :OFFICE USE: koo 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tthe 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/LOCATION (� L � of CENSUS TRACT <br /> Owner's Name Phone N <br /> Address <br /> City . . s <br /> Contractor's Nam L { L-_-) „ License #o?79pig Phone -o?a <br /> 14 TYPE OF WORK (Check): NEW WELL 'L DEEPEN -/-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> A SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Inditstr-ia-1 ;i-�..-�: Cable Tool Dia. of Well Excavation U, <br /> Domestic/private `` Drilled Dia. of Well Casing, <br /> ` <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 'B i . . . . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> n . <br /> PUMP REPLACEMENT: . /_7 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F! AL INSPECTION. f <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE_ <br /> FOR DEPARTMENT USE ONLY -- - -- <br /> PHASE I ' <br /> APPLICATION .ACCEPTED;;BY. c5afDATE 7- 7� <br /> ADDITIONAL COMMENTS: <br /> ,A �PHASR':.Ti OUT' 'INSPECTION P E TI FINAL INSPECTION <br /> INSPECTION_$Y:*. . ''_: DATE INSPECTION B f DATE <br /> . , F <br /> E H 1426 Rev. 1-74 ' r h/75 2M <br />