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_ SAN J OAQUIN LOCAL HEALTH DISTRICT <br /> TO-R:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. SUS-P <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS -PERMIT EXPIRES 1 YEAR PROM 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 /> Country Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> /03--��0�3 <br /> JOB ADDRESS/LOCATION f�f P �� !; ]� CENSUS TRACT <br /> Owner's Name d Phone (� <br /> Address City <br /> i <br /> { <br /> Contractor's Name �^ ..t ;r License 1*�"�'� Phone- <br /> TYPE OF 14ORK (Check): NEW WELL /? DEEPEN & RECONDITION /-7 DESTRUCTION %f <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 MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation /t <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 192. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic, Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor -1111�1 �67r id We) (!�4 <br /> Type of Pun4K H.P. <br /> PUMP' IIEPLACEMENT: / / State Work Done _��1 r •t# � <br /> PUMP .REPAIR: J-7 State Work Done <br /> ES•TRUCTION 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 puttingthewell in use. The above <br /> information is true to the-bes,� of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN FINA7L INSPE ON. <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEIle- AA1 DATE . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> + E H 1426 Rev. 1-74 1-74 2M <br />