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1 <br /> SAN JOAQUIN LOCALHEALTH DISTRICT <br /> 7F-0E--OFFICE USE j 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781. + <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> ' THIS PERMIT EXPIRES 1. YEAR FROM DATE_ ISSUED Date Issued /0.' -7 <br /> (Complete In Triplicate) <br /> Application is tereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein describe This application is made in compliance with San 3oaquii <br /> County Ordinance :No.. 1$62 and the Rulera�kRegulations of theon Joaquin Local Health District. <br /> JOB ADDRESS/LOC ON :,; / CENSUS TRACT <br /> F <br /> Owner's Name PhZP <br /> 7b ' <br /> Addres,fJ - Cit <br /> Contractor's Name :f License 060-315 Phone <br /> TYPE OF WORK (Check) : INEW WELL/ / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> 'f Other <br /> ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 /> Industrial 'CableiToo1 Dia. of Well Excavation <br /> Domestic/private" Drilled' ` ` Dial of Well Casing <br /> ' <br /> Domestic/pub lic'NR r Driven , Gauge of Casing <br /> i Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> f Disposal , Other Other Information <br /> Geophysical '.Sutface Seal Installed—:By. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: % State Work <br /> UMP '.REPAIR: / / : State Work Done <br /> ' DES•TRUCTION OF _WELL: Well Diameter Approximate Depth <br /> IDescribe Mater"ial`and°Procedure <br /> I :hereby agree to comply with all Jaws and regulations of the San Joaquin Local Health istri�t <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 thewell in use. The above <br /> information is true to::jthe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> , PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ,�� eP TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> y FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED.BY DATE p , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE LlI/FINAL INSPECTION' <br /> INSPECTION BY DATE INSPECTION BY ^DATE - -� <br /> 1177 2M <br /> E H 1426 Rev. 1-7'4 <br />