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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OrFICE USE: rf 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> • Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. IM 87 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 a d Regulations of the San oaquin Local Health District. <br /> JOB ADDRESS/LOCATION � ��- CENSUS TRACT <br /> Owner's Name Phone <br /> Address %�^ City ! <br /> Contractor's Name e.t! � -�'� icense Jk- ,F6UK Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION /_/ DESTRUCTION /_7AL <br /> PUMP INSTLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 9 <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 /> T_ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Its <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: (,A <br /> PUMP INSTALLATION: Contractor <br /> Type ,of Pump ___ H.P. v <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 istrict , <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A FINAL Ijq SP CTION. <br /> SIGNED - TITLES <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE7�3 -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I I N ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1/77 _ " 2M <br />