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_ SAN JOAQUIN LOCAL HEALTH IISTRICT <br /> FOH OFFICE USE: �/h601 E. Hazelton Ave. , Stockton, Calif. <br /> • Telephone: . (209) .G6 6781 - <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -.2 •�G <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 /> ,s3� <br /> JOB ADDRESS/LOCATION - # CENSUS TRACT <br /> s <br /> Owner's Name 029 1Phone <br /> Address City <br /> Contractor's Name ���= - /�=� ��u License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /-7 DESTRUCTION /-J <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK /ap/ 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 Cab-le Tool Dia. of Well Excavation ' /d <br /> Domestic/private Drilled Dia. of Well Casing ( w <br /> Domestic/public Driven Gauge of Casing / 2- <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br /> Cathodic Protection �_ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 74 ZGS> l <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 <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 <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 /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE <br /> �MWI FWT PLAN ON REVERSE SIDE p <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> 2 <br /> PLICATION ACCEPTED BY /�? DATE 6 S���_ <br /> DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON PHASE III/ INAL INSPECTION <br /> PECTION BY DATE / INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 . <br />