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CD <� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFOR OFFI USE: �+� 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 Issue Oa 7 <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 Joequin <br /> County Ordinance No. 1862,and- the Rules and Regulations of the San Joaquin Local Health District. # <br /> V31—7 .. <br /> JOB ADDRESS/LOCATION 5d. CENSUS TRACT t <br /> i <br /> Dwner's Name e � b✓ Phone <br /> Address '1r 0 <br /> city <br />:ontractor's Name <br /> License # � ys�"Phone <br /> a <br /> CYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR />r/ PUMP REPLACEMENT /7 <br /> Other <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ^a <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 /> Industriai � ` Cable' Tool Dia. of Well Excavation m <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 />'UMP INSTALLATION: Contractor .� <br /> Type of .Pumpf' H.P.. <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP .REPAIR: .State aWor-k-.Done - / <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> end 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 /> FELL DRILLERS REPORT of the well and notify them before putting the.-well in use. The above <br />.nformation is true to the best of. my ledge belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING D A FINAL I ON. <br />'IGNED TLE _ <br /> ( W -OT nAX ON RE SE SIDE) 1 <br /> OR EPA MENT USE ONLY <br />'RASE I <br /> PPLICATION ACCEPTED BY DATE <br />.DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I41/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE &_ T <br /> E H 1426 Rev. 1-74 1177 - ` 2M <br />