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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./�� 71 <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 ang,th Rules and Rulat' ns the San Joaquin Local Health District. <br /> JOB ADDRESS/ TION CENSUS ZCT <br /> Owner's Name Phone _ <br /> Address city <br /> d `' w City <br /> ' C.1 ^� � . '7 License 4� 4 'l�� Phone <br /> Contractor's Name <br /> 222 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEP / RECONDITION /_/ DESTRUCTION /^] <br /> PUMP INSTALLATIONPUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / Ar <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 r\ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor awl W­' � <br /> � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r, <br /> Describe Materla—lap Materia—lapProcedure <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 <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 INSPECTIOI <br /> PRIOR TO G UTING AN A INA1 INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLYPHASE I <br /> Q q p -'7 <br /> APPLICATION ACCEPTED BY l%f DATE 04h l - 7 / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL SPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 7 7 <br /> E H 1426 Rev. - 1-74 <br /> n/77 , 2M <br />