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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. 77.3 9/p , <br /> THIS PERMIT EXPIRES 1 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 andg he/3ulesnd R ations of the San Joaquin Local Health District. <br /> [ I <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name I `7u� Phone. <br /> Address City ,y✓`Cif <br /> Contractor's Name i' r License itJ�Phone <br /> �I <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_7 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 E - ,.Drilled Dia. of Well Casing <br /> LA. Domestic/public Driven .,. Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal r Other Other Information <br /> Geophysical , -. -Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum _ H.P. <br /> PUMP REPLACEMENT: !/ State Work''Done' /`� <br /> PUMP .REPAIR:. a � / / -State Work Done <br /> DESTRUCTION 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 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 GROUTING,4e A FINAL INS 710 <br /> SIGNED TITLE <br /> DRAW PLIDT PLAN ON RE L7tSE SID0�, <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC P SE"J,,14FINAJ. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE. � 7 7 <br /> .e• <br /> 3/7b <br /> E H 1426 Rev. 1-74 <br /> i <br />