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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7;7- <br /> THIS <br /> 7-THIS PERMIT EXPIRES I 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 and Re Mations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q __ CENSUS TRACT <br /> Owner's Name Phone <br /> Address / " Iz <br /> d City <br /> Contractors Name License ��� 0 Phone <br /> i <br />' TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> jDISTANCE,;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 /> t 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 F . Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> ,PUMP INSTALLATION: <br /> '. : ' Type of Pump H.P. <br /> : PUMP REPLACEMENT: I I State Work Done1��M Z�4 <br /> f,...--.r.. .-. - ,..._ ..f�.,... . .�...�----•- -...-,. �- �,�,.t �,. -^--sem.-� . . "--.rte - �,r �-;.�-..�.. ..�..x�.,r_�;..- .. <br /> :PUMP -REPAIR: / / State Work Done`; v <br /> 1DES�TRUCTION OF WELL(: Well Diameter A Approximate Depth <br /> I t` Describe Material and Procedure <br /> I hereby agree toico ply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of .California pertaining to or-cregulating 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 themtbefore putting the well in use. The above <br /> [information is true to the best of my knowledge° and belief. I WILL CAJL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING A'N INAL NSPECTIO <br /> Jk <br /> SIGNED - TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> i' FOR DEPARTMENT USE .ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE P—/7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS& ThIIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE "7 <br /> Yi j 7 2M <br /> E H 1426 Rev. 1-74 �� <br />