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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. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l 76 } <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. 1$62 and ' he Rr and Re 1 "ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION d CENSUS T CT <br /> .c.l ,3 <br /> Owner's Name Phone <br /> l i <br /> Address / ` City <br /> Contractor's Name License 4F 4� Phone4() <br /> TYPE OF WORK (Check) : NEW WELL El- DEEPEN /TI RECONDITION /? DESTRUCTION /7 - - y <br /> PUMP INSTALLATION I / PUMP �REPAIR PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> w PROPERTY LINE M PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> •INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Nlk <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 Installed By: <br /> f _. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> -PUMP .REPAIR:, State Work Do <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 DAMS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 7 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 AND A FINAL INSPECTION. <br /> SIGNED a.t , TITLE f �: <br /> D W.: ' T' PLAN 'ON RE iSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY j ' DATE 1Y -7_7�,�' <br /> ADDITIONAL COMMTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /&7- <br /> r - . <br /> E 11 1426 Rev. -1. 74 3/76 <br />