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" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO& OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ". Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Q 7r <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 CENSUS TRACT <br /> Owner's Name phone <br /> Address r j City <br /> Contractor's Name License Phone?j-1-f��3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 V <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> SEWAGE DISPOSAL FIELD j()Q CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVA'T'E DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation v <br /> XDomestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 60 <br /> Cathodic Protection J/Rotary Type of Grout <br /> Disposal �7� Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 <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 we11 '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 GROUPING AND A FIN L INSPECTION. <br /> SIGNED Ile TITLE <br /> (DRA14 PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY / DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY dl DATE <br /> '����/ /zZ G zP 0, 77 . <br /> E H 1426 Rev. 1--74 <br />