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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�T <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 Joaquin <br /> County Ordinance No. 1862 a-Ad the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �r /+�/ �°' +� CENSUS TRACT <br /> Phone <br /> �+'�� <br /> Address A5* + f/® �" 0. CitV / v Cz-/ <br /> Contractor's Name ` . `�Ce�^i License # Phone <br /> { TYPE OF WORK (Check) : NEW WELL ( DEEPEN / / RECONDITION_/_/ DESTRUCTION /? <br /> PUMP INSTALLATION � PUMP REPAIR I I PUMP REPLACEMENT /? <br /> Other 1 / <br /> DISTANCE TO NEAREST: SEPTIC TAN 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 'Oe -i!_ <br /> Domestic/private .Drilled Dia. of Well Casing v <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal c1G� a1, <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information g <br /> r 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 District <br /> WELL DRILLERS REPORT�r°f-tile well and notify them before putting the -well in use. The above <br /> information t to the es:t o. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR��i� DINAL <br /> SIGNED : '[ L TITLE <br /> D W <br /> V'11111 PLAN 'ON RE RSE SIDE} <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY ,��, <br /> ADDITIONAL COMMENTS: PHASE I /FINAL INSPE IO <br /> PHASE I ROUT INSPECTIO DATEf <br /> INSPECTION BY DATE INSPECTION BY <br /> 7� 3/76 2M <br /> E H 1426 Rev. 1-74 <br />