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` I SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Permit No. ,7 7 y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) <br /> Application hereby made to the San Joaquin Local. Health District for a permit to construct <br /> and/or install the work herein describeA. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 ,and the les d Regu tons of the San Joaquin Local Health District. <br /> III JOB ADDRESS/LOC ION I - ' C SUS TRACT <br /> `r <br /> Owner's Name 7 <br /> Address City <br /> ' License , )-14 J'Y <br /> ! <br /> Contractor's Name � Phonf. <br /> N <br /> TYPE OF WORK (Check) : NEW WELL /��/ DEEPEN '/ I RECONDITIO /_� DESTRUCTION /-7 <br /> PUMP] INSTALLATION I I PUMP REPAIR -j% PUMP REPLACEMENT /7 <br /> Other <br /> � r <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 /> r Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing G <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 <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT State Work Done <br /> PUMP-REPAIR: State Work D <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k 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 i <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to thelbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED I TITLE <br /> t <br /> (DRAW PV6T PLAN ONRE FRSE SIDE) <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I t <br /> APPLICATION ACCEPTED BY DATE �+ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> { INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 <br /> E H 1426 Rev. 1-74 <br />