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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No7/—j� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��7 <br /> (Complete In Triplicate) I <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 0rd'n nce No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ CENSUS TRACT <br /> Owner's Name . Phone t f <br /> Address ` ` <br /> City <br /> Contractor's Name - . ✓ License # jg_;&XPhone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION-/—/- DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK �. `D SEWER LINES 0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD�V CESSPOOL/SEEPAGE PIT Z4M OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL)(-Z& 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 7 40 <br /> Irrigation Gravel Pack Depth of Grout Seal (1 <br /> Cathodic Protection �_ Rotary Type of Groute-,n ens' <br /> Disposal Other Other Information do <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.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 Distri <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 GROUTI-NG ANP 4WIN4LIN PECTION. <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 /> PHgE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY hA A DATE /7-J. -�_� INSPECTION BY _ DATE <br /> me r- �r� s o� �/ Oral /1/a IN12- pe4- z�� 4e <br /> E H 1426 Rev. . 1-74 bra �l/ �rD �.�-, �rca �•� <br />