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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBrOFFICE-- USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL.-CONSTRUCTION OR PUMP PERMIT Permit No. ��fw <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 4 <br /> x . (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> :and 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 /> ix-73 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> t <br /> Address 27.%97" <br /> City <br /> Contractor's NameACt�ADD . - Licensees Phone <br /> ut <br /> TYPE OF WORK (Check): NEW WELL ,L•7T DEEPEIq /7 RECONDITION /7 DESTRUCTION —5 <br /> PUMP INSTALLATION L7�'PUMP REPAIR /-7-pump REPLACEMENT /-7 � t <br /> ' Other /? <br /> DISTANCE TO NEAREST: SEPTIC TANK S,f°�- SEWER LINES _ �� -f 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 /> omestic/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 s <br /> Geophysical Surface Seal installed B A. F <br /> PUMP INSTALLATION: Contractor 4, <br /> Type of Pump .. ' s�1J- r H.P. <br /> PU14P REPLACEMENT: L7 State Work Done <br /> PUMP '.REPAIR: L7 State Work Done ` �= # <br /> ' :.•_.�..........:.;�.., <br /> ,�E,SeRUCTION OF WELL: Well Diameter ga Approximate Depth <br /> Describe Material sand-Pr-ocedure" ----�- <br /> f <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 wi'11 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-bestof• my,knowledge and belief. I WILL CALL' FOR A -GROUT INSPECTION i <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED � � '-'- y <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i t <br /> PHASE I L <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: s <br /> PHASE ROUT INSPECTION ` ', rVP_HASE :III FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION 8S-' DATE <br /> y f <br /> E H 1426 Rev. 1-74 1-74 2M :_ <br />