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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. CAN <br /> NED <br /> Telephone : (209) 4 -678 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 /S4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 - <br /> ��D� <br /> (Complete In <br /> Application is hereby made to the SanJoaquinTriplicate) <br /> Local Health District for a permit to construct v <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 /> �s 3S- <br /> JOB ADDRESS/LOCATION - At CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name z_ License 11jrp 7 Phone ?4o, - d <br /> TYPE OF WORK (Check) : NEW WELL -0 DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATIONX PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /,'gyp/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ,n <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 /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal p ' <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed_ By: <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump V, H.P. f- <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 /> SIGNED TITLE <br /> -DRAW FWT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> HASE I <br /> PPLICATION ACCEPTED BY DATE �~ <br /> )DITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/,FINAL INSPECTION <br /> ►SPECTION BY DATE ' / INSPECTION BY DATE 7, <br /> E H 1426 Rev. 1-74 . <br /> 3/76 2M <br />