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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAr F'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f. <br /> Telephone: (204) 466-6781 GI <br /> APPLICATION FOR WELL CONSTRUCTION.QR 'PUMP PERMIT Permit No. <br /> F THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J2-,7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San. Joaquin Local Health District for a permit to construct <br /> and/orinstall the work Herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> E JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's NameC. g 4'." Phone <br /> Address F oe- <br /> City � . <br /> Contractor's Name a- Licensep �� � <br /> l X137 hone = <br /> --- - <br /> TYPE OF WORK (Check): :4 NEW WELL/? DEEPEN -/-7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> F. 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 Casing C <br /> ! Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> k <br /> Geophysical Surface Seal Installed By: <br /> PUMP. INSTALLATION: Contractor &A00e <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: State Work Done �.. <br /> IV <br /> PUW REPAIR: /7 State Work Done <br /> PES�TRUCTION OF WELL: Well Diameter Appicoximate 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 owle4 lizeAnd-be ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 9,LORING, AND FINAL INSPECTI <br /> SIGNED', <br /> (DRAW PLAN ON ME SIDE) - <br /> Pff DEPARTMENT USE ONLY <br /> PHASE I -r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PrSEg/FINA14 INSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> 1 E H' 1426 Rev. 1-74 1-74-7R <br />