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f - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT G <br /> FOE OFFICE USE: Led <br /> � Poo1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26-462- <br /> F G7 7 <br /> " THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby tirade 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 :� , City - <br /> Contractor's Name License # Phone ' S <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/% PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE TIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL V! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled r Dia. of Well Casing �1 <br /> Domestic/public Driven Gauge of Casing <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ Other Other Information <br /> Geophysical ' <br />` Surface Seal Installed By: <br /> G PUMP INSTALLATION Contractor <br /> f �r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: %Y/ State Work Done &�O/ <br /> A I 1P 209 <br /> PUMP .REPAIR � 1=�" Stote"Work`Done = -_ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth j <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 k <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. x <br /> SIGNED TITLE <br /> �'TDRAW7PLOT PLAN 'ON REVERSE SIDE) V <br /> PHASE 'I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION �ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 7 <br /> 7 ,� ' G <br /> PHASE II GROUT INSPECTION PHASE III/FINAL-INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 `Rev. 1-74 3/ 214 <br />