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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. 74- i0,Fk"/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued f-� 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 Reg u�a tions of the San Joaquin Local Health District.. <br /> t� <br /> JOB ADDRESS/LOCATION _ CENSUS TRACT <br /> Owner's Name � Phone <br /> Address <br /> Contractor's Name License Phone 92 V <br /> TYPE OF WORK (Check) . NEW.WELL-'/ DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / /. -. PUMP REPLACEMENT I7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER t <br /> ' PROPERft LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL g <br /> INTENDED USE "TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation <br /> F L-_�omestic/private Drilled Dia. of Well Casing <br /> t : Domestic/public, r Driven Gauge of Casing Z► `(� <br /> Irrigation - Gravel Pack Depth of Grout Seal <br /> ' <br /> Cathodic+Protection ---F--Rotary Type= of Grout - ` <br /> Disposal + __Other •-Other-Information <br /> Geophysical , f,. ,.,. Surface Seal Installed B �.- <br /> 'PUMP INSTALLATION:- = . Contractor <br /> Type ,.of Pump H.P. <br /> • <br /> PUMP REPLACEMENT: ", "./ / StateWork Done <br /> I�I PUMP .REPAIR: / / State'Work Done �e 1 <br /> DES-TRUCTION OF. WELL: Well Diameter Approximate Depth <br /> r Describe Material and Procedure <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-knowledge and belief.' I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUITING .AND A FIAAL ASPECTION. f <br /> SIGNED ;TITLE <br /> DRAW' PLT PLAN ON RE ERSE SIDE) <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r APPLICATION ACCEPTED fBY DATE - -?�, <br /> ADDITIONAL COMMENTS: <br /> PHAS II GRO T INSPECTIO PHAS III/FI AL INSPECTIO <br /> j INSPECTION BY DATE `` INSPECTION� BY DATE77-7 <br /> IrE H 1426 Rev. 1-74 3/76 2M- �, <br />