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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. 81G Jas <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4� 3� CENSUS TRACT <br /> Owner's Name Phone <br /> Address City 9076-X <br /> Contractor's Name ✓/tel //1 - License #GPhone <br /> i <br /> _ _ 1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT A7 p <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER l <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 `v <br /> Irrigation- - Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Infoimation <br /> Geophysical Surface Seal 'Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump V H.P. <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> PUMP .REPAIR: / / State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 6,! <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 CAL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PtOT PLAN 'ON RE ERSE <br /> . ,SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ fes/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r <br /> E H 1426 Rev. 7-74 <br /> 3/76 2M <br />