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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: 1601 E. Hazelton -Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 + <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7—7�f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / � 4 <br /> r <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. <br /> JOB ADDRESS/LOCATION - e .�4CENSUS TRACT <br /> 0 <br /> Owner's Name Phone <br /> AddressFr City S'�zrr_/�7`7►� <br /> Contractor's NameLicensePhone <br /> 3 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /—T DESTRUCTION /_7 ' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / ' <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Caging._ _ <br /> Domestic/public Driven Gauge of Casing \n <br />--,.---Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type' 'of. Grout <br /> Disposal : y. ; ,•. Other Other Information <br /> Geophysical t x` '� y ,-Surf ace..Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> TYPe' of Pump ,� H.P. { <br /> PUMP REPLACEMENT: / / State Work bone R "` <br /> - k <br /> PUMP REPAIR: / /' State Work Done <br /> DESTRUCTION OF WELLW <br /> _: e11Ziameter A pproxi6ate Depth <br /> Describe. -Material-;and Procedure :w <br /> i <br /> I hereby agree to comply with all laws and regulations of tlie,Sail Joaquin Local Health District <br /> and the State of California pertaining to or regulating`we11�'canstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will fur�nish�he San*Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and.notify them"b'efore putting the .well in use. The above <br /> information is true to the best of myknowledge. and belief. I WILL CALL FOR A GROUT INSPECTION <br />,PRIOR TO GROUTING ND,A FINAL INSPECTION:, <br /> SIGNED TITLE ' <br />'I (DRAW PLOT PLAN ON REVERSE SIDI? <br /> FOR DEPARTMENT USE ONLY ; <br /> APPLICATION ACCEPTED BY"'� f �/1ii'� ' DATE <br />'ADDITIONAL COMMENTS: ` <br /> PHASE II 'GRO INSPECTION 'INAI4INSPECTION <br /> iINSPECTION� BYDATE INSPECTION BY DATE <br /> w _ ' <br /> 1f77 _. 2M <br /> E H 1426 Rev. 1 -74 pY -- <br />