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° SAN JOAQUIN LOCAL .HEALTH DISTRICT f <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. Imo` t=' <br /> i Telephone: (209) 466-6781 ra <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-7/ <br /> THIS YPERMIT EXPIRES .1 YEAR FROM DATE ISSUED. Date Issued/ :-I r <br /> (Complete In Triplicate). . <br /> Application is here ade to the San Joaquin Local Health District for a permit to construe <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 d Regula 'ons of th an .Ja quip Local Health District. <br /> r <br /> JOB ADDRESS/LOC .16 -711CENSUS TRACT <br /> ° <br /> Owner's Name Phone' <br /> City -� <br /> Address <br /> Contractor's Name C j' La cense Phone 0� <br /> ` TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /7 <br /> PUMP INSTALLATION 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 /> 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 Aa Type of Grout <br /> Disposal OtherOther Information <br /> j Geophysical _ A urface Seal Installed. T3 : <br /> � PUMP INSTALLATION: Contractox[�'� <br /> Type of Pump L + H.P. . <br /> `PUMP REPLACEMENT: / /._ State Work Done. <br /> RUMP-:REPAIR: ../�-/. ._..5.�.at:� Work-Done . ... _�_. <br /> f <br /> DES•TRUCTION 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 <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 AN INAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE/a <br /> k APPLICATION ACCEPTED BY <br /> r ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION PHASE I/FIN INSPECTION <br /> DATE <br /> INSPECTION BY <br /> INSPECTION BY DATE ,t! , <br /> iifl7 2M <br /> F - <br /> :E H 1426 Rev. . 1-74 " <br />