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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORI'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR :PUMP PERMIT Permit No. 7-S-.341ji0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Rul and Regulations of th San oa n Local Hea th ist� <br /> �� 0 _:je <br /> JOB ADDRESS/LOCATION l� <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> AddressDov City <br /> Contractor's Name License #15fn1ea Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/ RECONDITION /TT DESTRUCTION /"7 <br /> PUMP INSTALLATION /U7 PUMP REPAIR /-7 PUMP REPLACEMENT <br /> 1-7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 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 f <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bv. ; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PM ,REPAIR: /? State Work Done <br /> I <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> 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 GROUTING AN INAL INSPECTON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -'� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION PHAS-E INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1E H 1426 Rev. 1-74 1-74 2M f <br />