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�++ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F OF�''ICE 1.601 E. Hazelton Ave. Sto11ckton,t ckton, Calif. i <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9'30'7 <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 <br /> t ... _ Phone <br /> Address <br /> City <br /> Contractor's Name, <br /> _ License # L Z;Q--Phone <br /> TYPE OF WORK (Check) : NEW WELL j / DEEPEN /_/ RECONDITION /Vj DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/ <br /> Other PUMP REPLACEMENT <br /> / / i — <br /> DISTANCE TO NEAREST: SEPTIC TANK _ .. � <br /> SEWAGE DISPOSAL FIELDMER LINECESSPOOL/SEEPAGE PIT _TIC WELL <br /> OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMES _ <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 —'------ -�; <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP _REPAIR: / r/ State Work Done �� , <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure --- Approximate Depth <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 ko edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G U IMG AND A FINAL I TION <br /> SIGNED <br /> ,f <br /> TITLE <br /> (D 6 PLO AN ON VERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � / - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: _ DATE 3d <br /> PHASE II GROUT INSPECTION P E I/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE �;' <br /> E H 1426 Rev. - I-74 n%%7 2M <br />