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i <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi.4FFICE USE: �1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued �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 work11,herein described. This application is made in compliance with San Joaquin <br /> h County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /�'c CENSUS TRACT <br /> Owner's Name I� Phone "' <br /> IM <br /> Address ;p City <br /> Contractor's Name ��' Licenseiq �f Phone <br />' TYPE OF WORK (Check) :,ANEW WELL / / DEEPEN / / RECONDITION /, DESTRUCTIONS/� <br /> .PUMP INSTALLATION / / PUMP REPAIR�/ /� #PUMP REPLACEMENTt <br /> fD'ther F-7 <br /> e <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY-LINEP-RIVATE -DOMESTI-C 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 <br /> t Domestic/public; , Driven i Gauge of Casing til <br /> i Irrigation tGravel Pack .Depth of Grout Seal <br /> Cathodic Protection Rotary 1 Type of Grout <br /> Disposal ,,Other Other Information � <br /> Geophysical -� Surface Seal Installed By: q <br /> r PUMP INSTALLATION: Contractor <br /> 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done , a <br /> PUMP REPAIR: � t <br /> State. Workk:Done <br /> DESTRUCTION OF WELL: Well ,Diameter . Approximate Depth <br /> - Describ.e Material and Procedure <br /> I hereby agree to comply with all laws and-regulations of the San Joaquin Local Health District <br /> ` and the State of Califoinia pertaining to or regulating well "construction. Within FIFTEEN DA�,S <br /> after completion of my work, on anew well,-.I will-furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT 6fthe'w6 ll 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 FORA GROUT INSPECTION <br /> , PRIOR TO GRQkVING AND%AlpFINAL I.NSPECTION. <br /> SIGNED - 9 .TITLE - QQ J <br /> .Ii! (DRAW PLOT PLAN ON .REVERSE_..SIDE) <br /> f FDR DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY;. j j DATE• -fie-7z <br /> ADDITIONAL COMMENTS: Ij <br /> PHASE GROUT INSPECTION PHASE jV11FYM INSPECT ON <br /> INSPECTION BY jj DATE INSPECTION BY 4K DATE ? <br /> E H 1426 Rev. -74 1177 2M <br />