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�© SAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> FOS�OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calix. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Data Issued T d - <br /> .. • I (Complete In Triplicate) <br /> APPlication is hereby made :to the San Joaquin Local Health District for a permit to construct <br /> and/or instar, the.work herein described. This application is made in compliance with San Joaquin <br /> Comity Ordinance No.1*1$62 and the: Rules and R ulations of ,ihe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION..$ -, •` <br /> ;- CENSUS TRACT <br /> Owner's Dame <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> f �License f{Eg Phone b <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN 1_7 RECONDITION F7 DESTRUCTION /_7 <br /> I PUMP 'INSTALLATION /_7 PUMP REPAIR 1-7-Pump REPLACEMENT <br /> Other / l <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES <br /> SEWAGEIDISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER J <br /> r <br /> INTENDED USE <br /> al PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4 <br /> TYPE OF WELL CONSTRIfCTION SPECIFICATIONS r <br /> _ IndustriCable Tool Dia. of Well Excavation v ll <br /> Domestic/private ' Drilled <br /> _ Domestic/public Dia. of Well Casing <br /> Irrigation <br /> 1 Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection � Rotary Type of Grout <br /> _,_,Disposal _�� Other <br /> Geophysical --�� Other Information <br /> Surface Seal Installed B : j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> ' <br /> CEMENT <br /> PUMP REPLA . <br /> - . � Sate Work Done <br /> PUMP `.REPAIR; /-7 State Work Done <br /> EMUCTION OF WELL: Well Diameter " <br /> i <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 ' 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... <br /> information is true to the bee't.of. my-knowledge and belief. I WILL The above <br /> PRIOR TO GROUTING AND A F INSPECTION, CAIS OR 'A 'GROUT INSPECTION <br /> SIGNED01 <br /> TITLE <br /> I. <br /> ZAVII PLOT PLAN ON REVERSE SID `" <br /> PHASE II FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL, COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE PHAS I INSPECTION <br /> T , INSPECTION BY DATE rf--�2-,25 , <br /> E H 1426 Rev. 1-74 <br />