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` o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO�r'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74t- Steel <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued eg-/�'-7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local H alth rict for a permit to construct <br /> and/or install the work herei Th�p o made incompliance with San Joaquin <br /> Count Ordinance No. 1862 ans,�r u d 1 San Joaquin Local Health District. <br /> JOB ADDRESS�' 1 ry r'l�v s[ /??� �i CENSUS TRACT <br /> Owner's Name -� `� �� .. Phone <br /> Address City <br /> Contractor's Name f /Z�fi� ` License __��Phone <br /> TYPE OF WORK (Check): NEW WELLs,Iv DEEPEN /? RECONDITION /=T DESTRUCTION /-7 <br /> PUMP INSTALLATION / ] PUMP REPAIR /% PUMP REPLACEMENT /-7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK VZJ SEWER LINES Q PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CE SPOOL/ IT /ODo,--OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WV "-PUBLIC DOMESTIC WELL -e-- <br /> INTENDED <br /> ELL -e - � * <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Weil Excavation 40 <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: Contractorr ,Tire <br /> Type of Pump H.P. <br /> PUMP REPLACEMEi�1T: / / State Work Done <br /> PUMP ,REPAIR: L7 State Work Done - - <br /> R S•TRUCTION 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 GROUTING A VALE CTION. <br /> SIGNED TITLE <br /> D T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 5„ • <br /> t E H 1426 Rev. 1-74 1-74 2M <br />