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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 7�Y / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _l <br /> (Complete In Triplicate) Oe-7- 040 -Z� <br /> Application is hereby made to the San Joaquin cal Health District for a permit to constY�uct <br /> and/or install the work herein described. application is made in compliance with San Joaquin , <br /> County Ordinance No. 1862 and the Rules an egulations of the San o uin Local Health District. <br /> JOB ADDRESS/LOC 0 7 SirTRACT <br /> Owner's Name Phone J <br /> Address <5 6 Cit <br /> Contractor's Name License /6P>3 )*onet <br /> TYPE OF WORK (Check) : NEW WELL 1-7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT f <br /> Other /_7 -- <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 Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f State Work Don <br /> PUMP -REPAIR: / / 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informatj:on is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR -TO ROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE aA 4144,J- ---- <br /> (Dk& WT PLAN ON UVERSE S ID-ET <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q " <br /> APPLICATION ACCEPTED BY A_0 �� DATE G 7 <br /> ADDITIONAL OONNENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426Bev. 1-74 3/76 <br />