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SAN JOAQUIN LOCAL HEALTH DISTRICT. , <br /> FOE,OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. --7S 3 A�G.J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Is <br /> sued g��7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 /> { <br /> JOB ADDRESS/LOCATION �--- CENSUS TRACT <br /> Owner's Name F �' zz Phone <br /> Address c <br /> _ •' • City <br /> Contractor's Name License V . , Phone <br /> TYPE OF WORK (Check): NEW WELL /'7 DEEPEN '/_7 RECONDITTON F7 DESTRUCTION T j <br /> PUMP INSTALLATION -/ / PUMP REFAIR /-7 PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER {/� I <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 .Ij <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel PackDepth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal OtherOther Information <br /> Geophysical Surface Seal Installed By: j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1 <br /> PUW 'REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: <br /> /-7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth - i <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 GROUT NG AND A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY = j DATE l -y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PYAE 11INAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> E H 1426 Rev. 1--74. E <br /> . !� _�' JU-75--- <br /> 75-_-2ND <br />