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r SAN JOAQUIN <br /> LOCAL HEALTH DISTRICT <br /> FOFi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 �_)/3� <br /> �a APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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 n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . /�7c5-6—v CENSUS TRACT <br /> Owner's Name _ ���`�' �' Phone <br /> Address �. '-� -�►" //< City <br /> Contractor's Name License PhoneQ _ � <br /> -d <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION X1 PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 B <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 pf the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DA�'S <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 CA OR A GROUT INSPECTION <br /> PRIOR TO GROUTING FTN IN PE TION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /k/-L/4 <br /> � / DATE ; 3 <br /> APPLICATION ACCEPTED BY Gk/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE WA/FIN4L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE IL-73'1-7- <br /> 1 f 77 2M _-- <br /> E H 1426 Rev. 1-74 <br />