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All <br /> 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. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 4 <br /> t (Complete In Triplicate) -- <br /> Application is Aereby 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 /> `Z2r 2 �E i <br /> JOB ADDRESS/ CATION, G <br /> .lC � CENSUS TRACT -z`�I�tob�03 <br /> Owner's Name > <br /> Phone <br /> Address <br /> City ' �r <br /> Contractor's Name <br /> License # c�d�13 Phone c` <br /> } <br /> TYPE OF WORK (Check): NEW WELL 'o DEEPEN / / RECONDITION / DESTRUCTION /_7ti <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /� <br /> Other /% <br /> DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES -L�� PIT PRIVY T �) <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OAR <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 < <br /> _ irrigation X. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 8 : <br /> PUHP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P.— <br /> PW REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Dane <br /> DFS•TRUCTION OF WELL: Well Diameter <br /> 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 puttingthewell in-use. The above <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION . <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> G TITLE /Z 4 -71, <br /> (DFAW PLOT P-I"-(OW REVERSE SID " <br />'HASE I FOR DEPARTMENT USE ONLY <br />�iPPLICATION ACCEPTED BY DATE <br />►DDITIONAL COMMENTS: <br /> PHASE II GRO T INSPECTION P I FI INSPECTION <br />[NSPECTION SY ATE INSPECTION B DATE - —77 <br /> ��- �' <br /> E H 1426 Rev. 1,74 <br /> (A 1177 - 2N <br />