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k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi;OFfICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z6-S-37. 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-7-116 <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 - .�� :._ `�-' <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address X) H, City <br /> Contractor's Name f, `` + <br /> License # 71,jPhone _ kP 7.. <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/-7 RECONDITION /7 DESTRUCTION /-T <br /> PUMP INSTALLATION j / PUMP REPAIR k-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 /> 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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor ell - � <br /> Type of Pump , H.P. s <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 a <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 knowledgead-4 elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS <br /> SIGNED `' E ;. 4 TLE r <br /> ON REV SE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY NX&A I A DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY T DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />