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I. <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR AX, SAN OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7&1 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued / 74f <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/LOCATIONCENSUS TRACT <br /> Owner's Name Phone --� <br /> Address �� f - <br /> City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/-7 RECONDITION /_-7 DESTRUCTIONAT <br /> PUMP INSTALLATION / / PUMP REPAIR —/—/ PUMP REPLACEMENT /7 <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 /> 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 installed By: <br /> i <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump <br /> H.P. } <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUNK? 'REPAIR; /-7 State Work Done <br /> ES.TRUCTION OF WELL: Well Diameter e" Approximate Depth key-1-17 <br /> Describe Material and Procedure <br /> it <br /> I hereby agree to comply With all laws and regulatlon6 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 <br /> PRIOR TO GRO TING AND A FINAL INSPECTION. INSPECTION <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE q - <br /> ADDITIONAL COMMENTS: <br /> PHASET i CTION _ PHASE I SPECTIO <br /> INSPECTION '' <br /> IATE <br /> INSPECTION, BY <br /> k1 E H 1426 Rev. I-74 <br />