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H 5AN JOAQUIN LOCAL HEALTH DISTRICT <br /> F09 OFFICE USE: 1601 E. IN <br /> Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7-5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .4= <br /> TEAS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e1-l7 7S_ <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 _ . � CENSUS TRACT <br /> Owner's Name 'i; - Phone <br /> Address - ' s City r ti <br /> Contractor's Name -'� �: � • ,' �. License 's° , r' Phone <br /> TYPE OF WORK (Check): NEW WELL/X-f-'DEEPEN _/7. RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /_7 PUMP REPLACEMENT f7 �1E <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> tr,"Industrial 1,.—Table Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing — ` Zm" <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary Type of Grout ;� # <br /> x Disposal Other Other Information <br /> i Geophysical Surface Seal Installed By: <br /> PUMP 'INSTALLATION: Contractor ' s <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / S tate-Work .Done <br /> PUMP .REPAIR: L State Work Done <br /> ,PE&TRUCTION OF WELL: Well Diameter, � Approximate `Depth <br /> Describe Material. and Prdcedure <br /> A <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District -F` <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 arid)belief. I WILL CALL FOR A GROUT INSPECTION-"t <br /> PRIOR TO GROUTING AND A FINAL INSPEjQION. <br /> SIGNED " �' � _." ' TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I h <br /> APPLICATION ACCEPTED BY f DATE <br /> ADDITIONAL COMMENTS: -— <br /> PHASE If GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ,O DATE - _V �"INSPECTION BY DATE! <br /> 4 <br /> 1 <br /> � • E H 1426 Rev. 1-74 1-74 2M <br />