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° SAN JOAQUIN LOCAL: HEALTH-DISTRICT <br /> Fpr- OFFICE USE: 1601 E. Hazelton Ave:, Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> ZI APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -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 ENSUS TRACT <br /> Owner's Name - Phone <br /> ;.t <br /> Address " City <br /> t <br /> Contractor's Name 0 License Phone <br /> TYPE OF WORK <br /> (Check) : NEW WELL / / DEEPEN/_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION // PUMP REPAIR %/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE 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 Vy <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> J . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled„,- __. Dia., of,_Well1Casing, _. <br /> Domestic/public Driven <br /> P Gauge of Casing - <br /> Irrigation Gravel Pack Depth of Grout Seal �~ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> r <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: <br /> Contractor <br /> --- <br /> Type ofPump H.P. f <br /> PUMP REPLACEMENT: ` Stat'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 r6gulatioris of 'the San, Joaquin Local Health District <br /> and the. State of -California "pertaining ,to or regul:ating'raell 'con.st`ruction. - Within FIFTEEN DAYS i <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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT G D A FINAL INSPECT N.^ <br /> SIGNED t TITLE ; <br /> (DRAW PL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY T DATE -7-1 -7Z_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P A III/FNAL INSPECTION r . <br /> INSPECTION BY DATE INSPECTION BYWYt DATE Z!2: { <br /> E H 1426 Rev. 1-74 <br />