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=-"OFFICE' SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF USE: _ 1601 E. Hazelton Ave <br /> . , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l 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 <br /> CENSUS TRACT <br /> 77 <br /> Owner's Name Phone <br /> C-50(9' <br /> Address . _ <br /> City <br /> Contractor's Name License �� ,Z/3 Phone �� �)� /� <br /> TYPE OF WORK (Check) ; NEW WELL / DEEPEN '/ ./ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1,fi9 SEWER LINES PIT PRIVY <br /> ' SEWAGE�DISPOSAL FIELD y CESSPOOL%SEEPAGE PIT OTHER <br /> PROPERTY LINE019PDOMESTIC_ WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE/ TYPE OF WELL �, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool`_ Dia .ofd Well Excavation _U <br /> Domestic/private <br /> ---L�� D� tilled !. Dia 'j_of Well Casing <br /> : <br /> Domestic/public' Driven �..��-Giuge of Casing <br /> Irrigation Gravel Pack Depth -of Grout Seal 4 i <br /> Cathodic Protection Rotaft--y�, Type of Grout r� j <br /> Disposal Other Other Information d <br /> Geophysical " 1. y Surface Seal Installed B <br /> F ! <br /> PUMP INSTALLATION: i C htractor s <br /> Type of Pump r H;p. <br /> PUMP REPLACEMENT:-" / / State Work Done <br /> PUMP .REPAIR: <br /> / / State. Work Done <br /> DESTRUCTION OF WELL: } Well Diameter 7 Approximate Depth <br /> I Describe Material and. Procedure <br /> r: <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 a best of my knofledge and belief. I WILL CALL FOR A GROUT IN <br /> PRIOR TO GROUT IO / <br /> SIGNED [ c�o TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY F <br /> PHASE I <br /> APPLICATION ACCEPTED BY t DATE ' 7 <br /> ADDITIONAL'COMMENTS: <br /> PHASE I.1 GROUT INSPECTION PHAI/FINAL INSP CTION <br /> INSPECTION BY DATE b' -_IS INSPECTION BY DATE <br />__ E H 1426 Rev. 1--74 1177_ ":oM <br />