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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> JOAt4FFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> If <br /> Telephone: J209) 46.6-:6181 <br /> I�. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7���sS� <br /> THIS PERMIT:EXPIRES 1 YEARFROM DATE ISSUED Date Issued <br /> • (Complete In •Tripli.cate) <br /> Application is hereby made to the 'San Joaquin .Local, Health District for a permit to construct <br /> and/or .install tie work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and gulatfons .of• the San Joaquin Local Health District. <br /> ., <br /> JOB ADDRESS/�,OCATION 7 <br /> �. s. <br /> CENSUS TRACT <br /> I <br /> Owner's Name Phone <br /> Address Cit <br /> : y <br /> Contractor'sName <br /> I� License # Phone d� � 1 <br /> TYPE OF WORK Check): NEW WELL/_7 DEEPEN '/_7 RECONDITION /_7 DESTRUCTION /? ' <br /> PUMP INSTALLATION / / PUMP REPAIR 1-7 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 /> Indus ' al Cable Tool" Dia. of Well Excavation <br /> _ M Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seas, <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 'Surface Seal Installed-By-. <br /> PUMP INSTALLA ION; <br /> ContractorC�d� , <br /> ff, Type of� Pump P . H.P. <br /> PUMP REPLACEMENT: 2, State Work Done d:;ja,0 �,�., r <br /> PUMP :REPAIR: /_7 State Work Done i. <br /> ES•TRUCTION Of WELL: Well Diameter i <br /> 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 <br /> and the Statelo€ California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completirn 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 id1litrue to the best.of. my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT9. ING FINAL INSPE ION. <br /> SIGNED ' <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> �! FOR DEPARTMENT .USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PARSE II GROUT INSPECTION P S I FINAL INSPECTION ` <br /> INSPECTION BY If 1, DATE INSPECTION BY DATECS <br /> lE HI� <br /> 1426 Rev. 1-74 <br /> _ _ i <br />