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tom" <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ro <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.-71-11 <br /> THIS PERMIT EXPIRES T. 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 Name - Phone_3(0 <br /> I <br /> Addregs"SQ Cit o <br /> y <br /> Contractor's Name ' !f ' { <br /> License __R07-wPhone �r <br /> f TYPE OF WORK (Check) : NEW WELLDEEPEN/ / RECONDITION F7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT- 1-7 <br /> Other <br /> EPLACEMENT /- <br /> Other % — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />` 1 INTENDED USE iTYPE OF WELL CONSTRUCTION SPECIFICATIONS`t <br /> Industrial Cable Tool Dia, of Well Excavation <br /> _ X Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ! a <br /> g on Gravel Pack Depth of Grout Seal j <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical Surface�Scal Installed yBy: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done D <br /> PUMP .REPAIR: # > } <br /> State Work Done 3 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate ,Depth <br /> Describe Materia]. and Procedure <br /> I hereby`..,agree: t.o_comply with all laws an.d 'regulat.ions of the San Joaquin Local;Health District <br /> and the State <br /> .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 AND A FINAL ,INSPECTION. r <br /> SIGNED TITLE - I+I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f. <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 'INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE o `J7 INSPECTION BY 111„�e DATE I/- F -77 i <br /> E H- 1426 Rev. . 1.-74 /•�-,� r ,1 -y �, �• ' ,�%7 _ 2M K r? <br />