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T JOAQUIN LOCAL HEALTH DISTRIC- <br /> 0-E OFFICE USE: 16O2-E. Hazelton Ave. , Stockton, Caaif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�= Qgs yo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f-_2:?- 6 <br /> (Complete In Triplicate) <br /> .pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaquin <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION � W CENSUS TRACT <br /> owner's Name Phone <br /> .ddress to City �� <br /> :ontractor's Name .l License Phone�� - <br /> 'YPE OF WORK (Check) : NEW WELL / / DEEP %/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTAL ION UMP REPAI / / P PLAC NT ' /7 <br /> Other <br /> )ISTANCE TO NEAREST: SEPTIC TANK SEWER IVES 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 Install%d By: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump V H.P. / <br /> 'UMP REPLACEMENT: j_/ State Work Done <br /> 'UMP .REPAIR: / / State Work Done <br /> )ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> sfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 4ELL 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 CAL FOR A GROUT INSPECTION <br /> 'RIOR TO G UTING AN NA INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN— ON SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1,zlx2 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO T INSPECTION PHASE III/FINAL INSPECTIOS <br /> INSPECTION BY TE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />