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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> F06 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Y� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sar: 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 Joaquir <br /> County Ordinance No. 1862 and/ theQ Rules and Regulations of the San Joaquin Local Health District. <br /> f JOB ADDRESS/LOCATION / / CENSUS TRACT <br /> Owner's Name Phone / IAO <br /> j Address dCity <br /> Contractor's Name License V/001)1 'hone / /r <br /> V <br /> f TYPE OF WORK (Check): NEW WELL '/-7 , DEEPEN 17 RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION/ PUMP/ REPAIR -/-7—pump REPLACEMENT <br /> Other J% <br /> DISTANCE TO NEAREST: SEPTIC TANK I ' 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 /> i Domestic/private Drilled Dia. of Well Casing <br /> i Domestic/public Driven Gauge of Casing <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 a <br /> Type .of Pump H.P. <br /> PUW REPLACEMENT.—. State Work Don; <br /> PUMP '.REPAIR:' op <br /> _ / / 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 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. kn©wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ' PRIOR TO GROUTING AND A FINAL INSPECTION': e, <br /> SIGNED t TITLE PA.,z A.,(? <br /> (DRAW PLOT PLAN ON REVERSE SIDE 47 <br /> FOR,.DEPAPJMENT 11SX ONLY" <br /> PHASE I ;. <br /> APPLICATION ACCEPTED BY ` R DATE 2@ 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 'INSPECTION PHASE II INAL INSPECTION <br /> r INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 _ r It/75_ 2M <br />