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,4)-t-d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfiOFFICE USE: 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone: (209) 46b4781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77)EZ,9)4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application 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/LOCATION Z v CENSUS TRACT <br /> Owner's Name Phone . � .� J <br /> Address City ' '� <br /> Contractor's Name r-�� <br /> License #42nge;-290hone !J <br /> TYPE OF WORK (Check): NEW WELL -/-J DEEPEN '/-7 RECONDITION /-T DESTRUCTION /7 <br /> PUMP INSTALLATION/ PUMP REPAIR/-7 PUMP REPLACEMENT /7 <br /> Other ET <br /> DISTANCE TO NEAREST: SEPTIC TANKfDD 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 Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal InstalledBye^ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Hop. <br /> PUMP REPLACEMENT: .. / / State Work one <br /> PUMP :REPAIR: / / State Work Done <br /> Y <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 GROUTING AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 3 <br /> APPLICATION ACCEPTED BY DATE�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />