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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: v 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7�V42-01 <br /> �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �f <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <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 Nam �_�i17-� Phone <br /> Address .- Z City <br /> Contractor's Name r� s� _ License #02 Phone &W X07 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /-7 DESTRUCTION /'7 <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other J-7 -- <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 WELLCONSTRUCTIONfSPECIFICATIONS X. <br /> Industrial Cable Tool Dia, of Well Excavation : <br /> Domestic/private 'i 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 T <br /> Disposal Other Other Information <br /> Geophysical a Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor TM <br /> Type of Pump _ H,.P,,11' . <br /> PUMP REPLACEMENT: / / State Work Done <br /> 9 _ <br /> PUMP .REPAIR: /. / State Work Dane E. A20- A) S j�jbrv� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> -� Describe Material and Procedure-, <br /> I hereby agree to comply;'w'ith: all, laws and regulations of the San Joaquin Local Health District <br /> and the State'of. California,.p!artaining 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 INSPECTIPN <br /> PRIOR TO GFbRUTING AND 'F AL INSPECTION. <br /> SIGNED TITLE <br /> DRAW P T' PLAN 'ON REVERSE SIDE) 7, � <br /> F9M PARTME7T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT 6 Z_VAL-1 /VDT DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/ INAL,INSPECTI N <br /> INSPECTION BY i DATE INSPECTION BY '' t_s DATE Weal <br /> E H 1426 Rev. 1 .74 3/76 2M I <br />