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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 7,91 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Il 76 <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 <br /> joQthe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �..-J ��J / ,� -�,�G�c-r- < CENSUS TRACT <br /> Owner's Name �x"�. �q� - Phone �- � <br /> Address l City <br /> Contractor's Name <br /> License � Phonef <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 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 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 <br /> Type of Pump y� H.P. <br /> PUMP REPLACEMENT: / State Work Done �, cw <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 knowledge and belief. I WILL CAL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING FINAL INSPECTION. <br /> SIGNED _ TITLE �.. °7 is <br /> (MUM PUT PLAN ON REVERSE SIDE) <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE he <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE I IN NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ Q-- p <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />