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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> ` FO tdFF'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ` (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74,1 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued :::. 7c� <br /> 4plicdtion <br /> (Complete In Triplicate) . <br /> is hereby �de 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. l 2 and the Rules and Regulations of, the San Joaquin Local Health District. <br /> l13 - ASO,-o/ <br /> E JOB ADDRESS/LOCATIo CENSUS TRACT <br /> Owner's Name Phone <br /> Address- �J � � � f City <br /> Contractor's Name License /W�pone 6Ard <br /> TYPE TOF�WORK (Check): NEW WELL j� DEEPEN '/_T RECflNDITiONDESTRUCTION %J"' <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT �f <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _411 <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 /> a -Domestic/private Drilled Dia. of Well Casing <br /> k Domestic/public Driven . Gauge of Casing _w I <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 /> { <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP 1EPAIR: State Work Don c� <br /> RES'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i 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 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 of- my knowledge and belief.. I WILL CALL FOR-A-GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED IMA TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> A <br /> t E H 1426 Rev. 1-74 1-74 2M <br />