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s ._- - ... -.. - .. 'I.IINIY�-�-eegl{�-•-wn.rx-R+'MMY��R�.'�G'+ "--'s'e�..v'r•Se. <br /> SANfJOAgUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601-9v*111azelton Ave. ,, Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 Joaqu k' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION =' <br /> CENSUS TRACT C <br /> Owner's Name <br /> Phone <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) NEW WELL/7 DEEPEN '/—/ RECONDITION /�/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other J-7 w <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 (1� <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 /> f <br /> Type of Pump H.P. kk <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br />-PUMP .REPAIR: - - / ../ —State -Work Done <br /> DESTRUCTION OF WELL: Well Diameter �+ Approximate Depth A <br /> Describe Material and Procedure / ledUZU 0 of rr/ <br /> 4r # <br /> I hereby agree to comply with all laws and regul ions of f-hi San Joaquin .L cal Health District n4 <br /> and the State of California .pertainiing to or regulating- well 'construction. Within FIFTEEN DAY y <br /> after completion of my work on anew 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'.xof my..knowledge' and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI AND NAL --INSPE.CTION. <br /> SIGNED - TITLE /PeFM/7 .S'eC770Af ` <br /> DRAW POT PLAN' ON RE FRSE SIDE) ,;17'is "•1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE [1 d 7 J, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3/76 2M k <br />