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SAN JOAQUIN�.00AL HEALTH DISTRICT r <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> t Teleplione : � (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7`j-&Y 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ( <br /> (Complete In Triplicate) <br /> Applic9tion 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/LOCATIONCENSUS TRACT <br /> Owner's Name Phone <br /> Address / I- L city <br /> Contr4etox's Name License Phone <br /> I4 <br /> TYPE OF WORK (Check) : NEW WELL / f DEEPEN %/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INST�ELATION PUMP REPAIR / / PUMP REPLACEMENT /_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 Casing6,zzJ6Q ti <br /> Irrigation y Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Ce,y <br /> -- <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By: AN, Xne-" <br /> PUMP INSTALLATION: Contractor S <br /> Type of Pump -- -- S'u 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 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 GROUTI% 4EDA F I <br /> SIGNED [ TITLE.; <br /> (DRAW PLOT PLAN ON REVERSE SIDE) T �' <br /> FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> 'j PHASE II GROUT INSPECTION y PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r DATE ) I <br /> E H1[1426 Rev. 1-74 <br /> 1177 _ 2M <br />