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�J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFOOFFICE xTJSE: Cn 160I E. Hazelton Ave., Stockton, Calif. <br /> Telephone : (209) 466-6.781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ <br /> 7 7-/O�3 <br /> L THIS PERMIT EXPIRES1 YEAR FROM DATE ISSUED Date IssuedIx- <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 Joaqui <br /> County Ordinance ,No. 1862 and the Rules and Regulations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Of <br /> Phone <br /> Y <br /> Address =t <br /> City <br /> Contractor's Name +b _ <br /> Licensejj;or?��f4�Phone <br /> TYPE OF WORK (Check) : NEW WELL /Z DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR — REPLACEMENT-- <br /> Other <br /> /� r <br /> _ / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKZf -t SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WCONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia, of Well Excavation � l <br /> Domestic/private Drilled -L�t�- - -- <br /> Dia, of Well Casing <br /> Do stir/public Driven Gauge of Casing" <br /> rrigation Gravel Pack Depth of Grout Seal E7 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal yp � - <br /> Other Other Information <br /> �GeophysicAl -�----- <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> - Type of Pump <br /> ' H.P. :tfi <br /> PUMP REPLACEMENT: _ State WxkiDone N <br /> PUMP .REPAIR: k 1'` sa 7a 30 /° <br /> / J State Work Done ?t <br /> , DESTRUCTION OF WELL: Well Diameter <br /> i Approximate Depth x <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 furni_s.h- the San Joaquin Local Health District a <br /> E WELL DRILLERS REPORT of the well and notifythem 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 A NAL INSP CT <br /> SIGNED <br /> ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE «---7 Z-^� <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY — P /FINAL INSPECTION <br /> DATE """`-"INSPECTI-ONBY-- - ---DATE` <br /> E H 1426 <br /> Rev. - I-74 <br />