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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /0/// <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'Vdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB AD 10 CENSUS TRACT <br /> 42 <br /> Owner's Name Phone <br /> Address - City <br /> a ��Contractor's Name _ License # / hone <br /> 'TY-PE -OF-WORK-(-Cheek): NEW`WELL - y 'DEEPEN /�/ `RECONDITION / /-DESTRUCTION"/ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS �, FIELD CESSPOOL/SEEPAGE PIT � OTHER \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL a <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 Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By: Ala 04 ` <br /> . PUMP INSTALLATION: Contractor Qf <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> "PUMP":REPAIR: - w / % -S-ta.te-.Work Done <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 AND .A FINAL INSPE.CTION. <br /> SIGNED TITLE n n <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 4 <br /> ADDITIONAL COMMENTS: ! �� <br /> PHASE II <br /> �UT PECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSP�:CTION BY DATE /0 <br /> . 6/77 _ 2M y <br /> E H 1426 Rev. - 1-74 y <br />