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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 /gip <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete 1h. 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. 186 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> I� <br /> JOB ADDRESS/LOCATION CENSUS TRACT s <br /> I <br /> Owner's Name r Phone ' <br /> Address city <br /> Contractor's Name Ik License # ' .�3LJPhone . ,5' <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /_7 RECONDITION /� DESTRUCTION /`7 <br /> PUMP INSTALLATION PUMP REPAIR/_7PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY oQ <br /> SEWAGE DISPOSAL FIELD tCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY- LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL . ' CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool, Dia ' .of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public I, 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 11 Surface Seal Installed By: <br /> PUMP .INSTALLATION: Contractor <br /> Type of Pump _ ,f � ,� - -. - H.P. - <br /> I!i <br /> PUMP REPLACEMENT: /77 State Work Done <br /> PUMP .REPAIR: __47 State=Work Done > <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply <br /> 'Mwith 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL INSPECTION. ' <br /> SIGNED _ TITLE 22ae=r-c4 .:2�z <br /> �( RA�WPLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE I <br /> APPLICATION ACCEPTED BY , : DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I11 FINAL INSPECTION <br /> INSPECTION BY 11 DATE INSPECTION BY DATE <br /> t <br />�' E H 1426 Rev. 1-70 - 05 2M - <br />