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1 <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209). 466--6781 <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Permit No.��"� k <br /> g ; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued F 3,o-77 <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 and the Rules and Regulations of the San Joaquin Local Health District. s <br /> JOB ADDRESS/LOCATION �0�� � �R n CENSUS TRACT <br /> Owner's Name i LL, Phone 3&9 <br /> Address b _ .. .. City <br /> Contractor's Name c , License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / /. T <br /> DISTANCE TO' NEAREST: SEPTIC TANKS'' 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 <br /> Domestic/private Drilled Dia. of Well Casing 7 <br /> Domestic/public Driven Gauge of Casing t <br /> Irrigation Gravel Pack Depth of Grout Seal .�M ' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> 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 /> r <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 i <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 al <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 GR UTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> T PLAN ONREVE <br /> (DRAW PLORSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 14 GROUT INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY DATE 4��v Z7 INSPECT,IQN BY - DATE j, v <br /> -T � <br /> E H 1426 Rev. - l-74 ��- .� j +�77 2M <br />